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A  PRACTICAL  TREATISE 

ON 

Disorders  of  the  Sexual  Function 
in  the  Male  and  Female. 


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BY 

MAX  HUHNER,  M.D. 

Chief    of    Clinic,    Gexitourinaey    Department,    Mount    Sinai    Hospital 
Dispensary,    New    York    City;    Formerly,    Attending    Genitourinary 
Surgeon,  Bellevue  Hospital,  Out-patient  Department  and  Assist- 
ant Gynecologist,  Mount  Sinai  Hospital  Dispensary,  New  York 
City;  Member,  American  Urological  Association,   American 
Medical  Association,  New  York  Urological  Association; 
Fellow  of  the  New  York  Academy  of  Medicine,  etc.; 
Author,     Sterility     in    the    Male    anl    Female 
AND  its  Treatme?;t,  etc. 


PHILADELPHIA 
F.  A.   DAVIS  COMPANY,   Publishers 

English  Depot 
Stanley  Phillips,  London 

1916 


COPYRIGHT,  1916 

BY 

F.  A.   DAVIS  COMPANY 

Copyright,  Great  Britain.     All  Rights  Reserved 


Philadelphia,  Pa.,  U.  S.  A, 

Press  of  F.  A.  Davis  Company 

1914-1916  Cherry  Street 


PREFACE. 


The  great  majority  of  cases  of  sexual  disorders  which 
come  to  the  observation  of  the  practitioner,  and  which  are 
at  the  same  time  amenable  to  treatment,  are  those  which 
fall  under  the  heading  of  sexual  neuroses,  and  it  is  these, 
therefore,  which  require  our  chief  consideration. 

Some  time  ago,  while  preparing  a  paper  on  Sexual 
Neuroses^®  which  was  subsequently  read  at  a  meeting  of 
The  Harlem  Medical  Association  of  New  York  City,  I 
asked  several  genitourinary  specialists  to  discuss  the  paper, 
but  was  met  with  the  reply  either  that  they  were  not  at  all 
interested  in  the  subject,  or  that  they  were  so  ignorant  of 
the  theme  as  to  be  unable  to  discuss  it.  One  of  the  gentle- 
men went  so  far  as  to  doubt  the  very  existence  of  such 
a  condition  as  sexual  neurosis.  Thus,  although  some  of 
these  gentlemen  had  made  an  enviable  reputation  for  their 
achievements  in  genitourinary  work,  not  only  in  this  coun- 
try, but  also  abroad,  they  had  entirely  neglected  this  por- 
tion of  the  specialty,  and  I  was  therefore  compelled  to 
resort  to  the  services  of  a  neurologist  to  open  the  discussion. 

As  a  matter  of  fact,  it  must  be  stated  that  most  of  the 
literature  on  sexual  neuroses  comes,  not  from  genitourinary 
specialists,  but  from  neurologists.  Nevertheless,  valuable 
as  the  work  of  neurologists  has  been  in  this  direction,  the 
genitourinary  specialist  finds  much  that  is  lacking,  and  this 

(iii) 


iv  Preface. 

for  very  obvious  reasons.  What  neurologist,  for  instance, 
is  able  to  perform  a  posterior  endoscopy,  or  to  interpret 
correctly  the  conditions  thus  seen  in  the  posterior  urethra? 
How  many  neurologists,  if  any,  are  there,  who  can  cor- 
rectly interpret  by  rectal  examination  the  difference  in  the 
feel  of  the  prostate  and  seminal  vesicles,  as  pathologically 
influenced  by  masturbation  and  withdrawal  on  the  one 
hand,  and  gonorrhea,  tuberculosis  or  senility  on  the  other? 
These  matters  are  clearly  beyond  their  domain,  yet  how 
necessary  are  these  data  for  a  correct  understanding,  and 
for  the  proper  treatment  of  the  conditions  under  considera- 
tion! As  I  will  show,  and  repeatedly  emphasize  hereafter, 
the  apparently  simple  procedure  of  massaging  the  prostate  is 
really  an  art,  and  I  do  not  hesitate  to  state  that  many  genito- 
urinary specialists,  especially  those  who  do  not  treat  sexual 
neuroses,  do  not  know  how  to  perform  it  properly.  That 
being  the  case,  how  then  can  we  expect  the  neurologist,  with 
little  if  any  training  in  genitourinary  work,  to  perform  it? 
Yet  this  method  of  treatment  in  sexual  neuroses  is  of  the 
utmost  value.  The  application  of  silver-nitrate  solution  to 
the  delicate  urethral  mucous  membrane  (which  is  especially 
hypersensitive  in  the  sexual  neurasthenic),  either  by  instilla- 
tion through  the  urethral  syringe  or  by  direct  application  to 
the  diseased  area  through  the  posterior  endoscope,  is  an  art 
that  requires  special  training  in  intra-urethral  manipulation, 
and  is  clearly  outside  the  domain  of  the  neurologist.  Many 
other  examples  might  be  given  to  explain  why  the  treatment 
of  sexual  neuroses  belongs  to  the  genitourinary  rather  than 
to  the  neurological  specialist,  but  the  above  illustrations 
are  sufficiently  striking  without  further  examples. 


Preface.  v 

In  discussing  this  very  point  with  a  neurologist,  I  was 
informed  that  he  considered  himself  perfectly  competent  to 
treat  impotence  in  the  male.  His  method  of  procedure,  he 
informed  me,  was  to  send  his  patient  to  a  genitourinary 
specialist  for  examination,  and  if  the  latter  found  nothing 
abnormal,  he  would  treat  the  patient  by  the  administration 
of  bromides  or  tonics  or  spinal  douches,  etc.,  sometimes 
also  passing  a  cold  sound  into  the  urethra. 

I  have  cited  this  little  episode  in  order  to  bring  out 
another  important  point  in  connection  with  sexual  neu- 
roses. The  failure  to  find  any  gross  lesion  in  the  genito- 
urinary tract  by  the  ordinary  method  of  examination  is 
by  no  means  a  guarantee  that  the  neurosis  in  question  is 
not  caused  by  reflexes  from  these  organs.  Any^  of  the 
distinguished  gentlemen  mentioned  in  the  first  paragraph 
of  this  preface  could  easily  have  given  a  clear  bill  of 
health  to  the  genitourinary  apparatus  in  any  particular 
case,  and  yet  the  latter  might  nevertheless  be  the  cause  of 
marked  neurotic  symptoms  affecting  remote  organs  of  the 
body.  The  genitourinary  specialist  who  but  occasionally 
peeps  through  the  posterior  endoscope,  or  one  who  even 
employs  it  more  often,  but  has  not  paid  particular  attention 
to  sexual  neuroses,  and  consequently  is  familiar  only  with 
the  gross  lesions  in  the  posterior  urethra,  which  are  the 
sequelae  of  chronic  gonorrhea,  would  doubtless  be  surprised 
to  be  told  that  some  insignificant  lesion,  such  as  a  slight 
congestion  in  the  region  of  the  verumontanum,  which  to  him 
might  seem  entirely  unworthy  of  notice,  might  be  the  very 
cause  of  the  most  profound  reflex  symptoms,  while,  on  the 
other  hand,  the  most  gross  pathological  lesions,   such  as 


vi  Preface. 

polypi  or  cysts,  are  apparently  borne  without  protest,  either 
by  the  genitourinary  apparatus  or  by  the  general  nervous 
system. 

It  should  be  remembered,  in  this  connection,  that  the 
major  portion  of  the  sexual  neurasthenics  come,  not  to  the 
genitourinary  clinics,  but  to  the  neurological  clinics.  And 
one  who  is  fully  familiar  with  the  feel  of  the  gonorrhea- 
infected  prostate,  the  tuberculous,  the  carcinomatous,  or 
the  senile  prostate,  might  still  be  entirely  unfamiliar  with 
the  prostate  of  the  sexual  neurasthenic.  I  repeat,  there- 
fore, that  the  finding  of  nothing  abnormal,  in  the  ordinary 
genitourinary  examination,  counts  for  very  little  in  the 
diagnosis  of  sexual  neuroses.  And,  as  for  the  treatment 
of  impotence  by  the  passage  of  a  cold  sound  into  the  ure- 
thra, it  is  like  the  giving  of  digitalis  for  heart  disease, — 
it  does  good  where  it  is  strictly  indicated,  but  its  indis- 
criminate use  is  merely  guesswork. 

I  do  not  wish  it  to  be  inferred,  however,  that  I  under- 
rate the  value  of  the  work  of  the  neurologists.  Far  from 
it.  They  have  done  most  excellent  work,  indeed  the  most 
important  work  in  sexual  neurasthenia.  The  works  of 
Freud  and  his  followers,  of  von  Krafft-Ebing,  Havelock 
Ellis,  Hamm.ond  and  Max  Herz  are  but  a  few  examples 
of  their  achievement  in  this  direction.  As  already  men- 
tioned, most  of  the  sexual  neurasthenics  find  their  way 
into  the  neurological  clinics,  complaining  of  the  most  di- 
vergent symptoms,  in  many  cases  not  at  all  suspecting  that 
their  sexual  apparatus  has  anything  to  do  with  their  symp- 
toms. It  is  the  work  of  the  skillful  neurologist  to  differ- 
entiate  these   symptoms   from   those  of  other  organic   or 


Preface.  vii 

functional  neuroses,  and  this  obviously  cannot  be  done  by 
the  genitourinary  specialist.  But  once  having  made  the 
diagnosis,  or  rather  having  excluded  other  nervous  ailments 
as  a  possible  cause  of  the  symptoms,  I  believe  it  to  be  no 
more  their  province  to  make  intra-urethral  applications 
than  it  is  their  duty  to  prescribe  glasses  for  a  headache 
they  have  fotmd  to  be  due  to  eyestrain,  or  to  do  gyneco^- 
logical  operations  for  neurotic  symptoms  resulting  from 
pathological  female  genitalia. 

There  has  existed  for  some  time  a  peculiar  state  of 
affairs  with  regard  to  sexual  neuroses.  On  the  one  hand, 
as  mentioned  in  my  opening  paragraph,  there  are  very 
many  genitourinary  specialists  who  are  so  engrossed  with 
the  major  surgical  work  of  the  specialty,  such  as  kidney, 
ureteral,  prostatic  and  bladder  surgery,  that  they  do  not 
care  to  bother  with  the  less  exciting  and  very  often  tedious 
work  of  treating  sexual  neuroses ;  while,  on  the  other  hand, 
we  have  the  neurologist,  who  by  his  training  is  particularly 
well  adapted  to  study  this  subject,  but  hasi  not  the  genito- 
urinary training  for  urethral  diagnosis  and  treatment.  For 
this  reason  it  came  to  pass  that,  although  I  have  done 
special  genitourinary  work  for  over  twenty  years,  and  have 
worked  in  many  clinics  both  here  and  in  Europe,  it  was 
not  in  these  genitourinary  clinics  that  I  became  acquainted 
with  sexual  neuroses,  but  only  after  I  had  associated  my- 
self for  several  years  with  the  neurological  clinic  of  Dr.  I. 
Abrahamson  of  the  Mount  Sinai  Hospital  Dispensary,  and 
studied  these  cases,  employing  the  urethroscope  wherever 
necessary,  and  frequent  palpation  of  the  prostate  and  sem- 
inal vesiclec  in  the  sexual  neurasthenic,  that  I  have  been 


viii  Preface. 

able  to  make  a  special  study  of  the  various  forms  of  these 
conditions.  In  other  words,  one  of  the  objects  of  the 
present)  work  is  to  bridge  the  gap  between  the  neurologist 
and  the  genitourinary  specialist. 

I  desire  to  express  my  thanks  to  Dr.  I.  Abrahamson 
for  his  uniform  courtesy  in  referring  to  me  considerable 
clinical  material  from  his  neurological  clinic  at  the  Mount 
Sinai  Hospital  Dispensary,  and  also  for  valuable  sug- 
gestions in  connection  with  his  own  specialty.  My  thanks 
are  likewise  due  to  Dr.  Charles  Herrman  for  placing  at 
my  disposal  the  cases  of  enuresis  which  came  to  his  atten- 
tion at  the  Vanderbilt  Clinic,  and  to  the  Medical  Record 
(New  York),  the  New  York  Medical  Journal,  The  Uro- 
logic  and  Cutaneous  Review,  and  the  Interstate  Medical 
Journal,  for  their  courtesy  in  permitting  the  use  herein  of 
articles  of  mine  heretofore  published  in  those  periodicals. 

In  the  following  pages  I  will  not  go  into  the  purely 
neurological  aspects  of  the  subject,  except  in  so  far  as  they 
become  necessary  to  elucidate.  I  will  not  discuss  such 
conditions  as  psychoanalysis  or  the  various  forms  of  sexual 
degeneracies  or  perversions.  These  belong  strictly  to  the 
neurologist,  as  their  pathology  belongs  rather  to  the  field 
of  abnormal  psychology  thanj  to  the  genitourinary  appa- 
ratus. Nor  will  I  discuss  herein  the  purely  venereal  dis- 
eases, gonorrhea,  syphilis,  and  chancroid,  as  these  form  a 
distinct  class  by  themselves  and  are  generally,  and  properly, 
accorded  a  separate  treatise.  The  subject  of  Sterility  has 
also  been  omitted,  as  I  have  treated  it  in  a  separate  work, 
to  which  the  reader  is  referred. 

The  subjects  to  be  discussed  in  this  work  will  be  Mas- 


Preface.  ix 

turbation,  Impotence,  Pollutions,  Priapism,  Clitorism,  Clit- 
oris Crises,  Satyriasis,  Nymphomania,  Frigidity,  Vaginis- 
mus, Dyspareunia,  Dyspareunia  in  the  Male,  Absence  of 
Orgasm  in  the  Female  during  coitus.  Enuresis,  Withdrawal, 
Continence,  and  Some  Unusual  Forms  of  Sexual  Neuroses. 
Most  of  the  material  herein  represents  the  result  of  original 
investigation  and  study,  never  before  published.  Some  of 
the  subjects  discussed  have  never  before  found  their  way 
into  English  medical  literature,  and  some  have  never  been 
discussed  at  all ;  so  that  even  their  names  had  to  be  invented 
by  me.  Especial  attention  is  given  throughout  to  treat- 
ment so  as  to  make  the  book  as  practical  as  possible.  It 
has  also  been  my  intention  to  make  the  discussion  of  each 
subject  complete  in  itself,  so  that  readers  who  happen  to 
be  interested  in  some  particular  subject  only,  need  not  be 
referred  to  other  chapters  of  the  work. 

Max  Huhner, 


320  Central  Park  West, 
New  York  City,  N.  Y. 


TABLE   OF   CONTENTS. 


CHAPTER   I. 

Masturbation.  page 

General  considerations.  Masturbation  in  boys  and  girls  before 
adolescence.  Etiology.  Pathology.  Precocious  cases.  Symp- 
toms. Diagnosis.  Importance  to  teachers  and  parents.  Course 
and  prognosis.  Importance  of  early  recognition.  Prophy- 
lactic treatment.  General  treatment.  Uselessness  of  constant 
watching.  Restraining  apparatus.  Pseudo-masturbation  in  in- 
fants.    Description.     Etiology.     Author's  opinion 1 

CHAPTER   II. 

Masturbation   in   the   Adult   Male. 

General  considerations.  Pathology.  Psychic  masturbation.  Symp- 
toms. Exaggerations  of  many  authors.  Fallacies  in  taking 
histories.  Importance  of  ruling  out  other  conditions.  Mas- 
turbation in  married  men.  Course  and  prognosis.  Illicit  inter- 
course not  a  cure  for  masturbation.  Treatment.  Importance 
of  gentle  massage.  Conclusions.  Masturbatio  interrupta. 
Masturbatio   incompleta.     Impotentia  masturbationis 13 

CHAPTER   III. 

Masturbation   in   the   Adult   Female. 

General  etiology.  Etiology  in  unmarried  adults.  Etiology  in  mar- 
ried adults.  Impotence  in  the  male  and  coitus  interruptus  as 
causes.  Methods  employed  in  masturbation.  Psychic  mastur- 
bation. Pathology.  Physiology  of  normal  coitus  in  the  female. 
Local  symptoms.  General  symptoms.  Course  and  prognosis. 
Reflex  symptoms.  Diagnosis.  Local  treatment.  General  treat- 
ment. Marriage  not  a  cure  for  masturbation.  Importance  of 
instructing  the  husband 38 

CHAPTER   IV. 

Impotence   in   the   Male. 

Definition.  Impotence  and  sterility.  Organic  impotence.  Defini- 
tion. Etiology  and  pathology.  Symptoms.  Diagnosis.  Prog- 
nosis.   Treatment.     Rudimentary  penes 55 

(xi) 


xii  Contents. 

CHAPTER   V. 
Functional   Impotence.  page 

Definition.  Sexual  vigor  a  relative  term.  Etiology  and  pathology. 
Libido,  erection,  ejaculation,  orgasm.  Mechanism  of  coitus  in 
the  end-organs.  Theory  of  verumontanum  in  coitus.  Nervous 
mechanism  of  coitus.  Pathology  of  impotence  from  excessive 
coitus.  Pathology  of  coitus  interruptus.  Pathology  of  im- 
potence following  masturbation.  Gonorrhea  and  impotence. 
Pathology  of  ungratified  sexual  excitement  as  a  cause  of 
impotence.  Cases  with  obscure  pathology.  Author's  opinion. 
Symptoms.  Disturbance  of  the  libido.  Disturbance  of  erec- 
tion and  ejaculation.  Author's  opinion  on  paralytic  impotence. 
Disturbance  in  the  orgasm.  Cases  of  congenital  weakness. 
Importance  of  recognizing  the  etiology  in  the  former  class. 
Local  symptoms  accompanying  impotence.  General  symptoms. 
Psychic  symptoms.  Diagnosis.  Importance  of  examining  wife. 
Importance  of  thinking  of  organic  nervous  conditions.  Prog- 
nosis. Treatment.  Intelligent  treatment  of  posterior  urethra. 
Importance  of  posterior  endoscopy.  Sexual  stimulants.  Orig- 
inal experimentation  61 

CHAPTER   VI. 
Psychic   Impotence. 

Definition.  Etiology.  Pathology.  Symptoms.  Misdirected  libido. 
Inhibited  libido.  Diagnosis.  Prognosis.  Treatment.  Impotence 
in  the  female.  Definition.  Etiology  and  Pathology.  Obstruc- 
tive impotence.  Neurotic  impotence.  Symptoms.  Diagnosis. 
Prognosis.     Treatment  99 

CHAPTER   VII. 
Pollutions    in   the   Male. 

Definition.  Author's  definition.  Diurnal  pollutions.  Nocturnal 
pollutions.  Defecation  spermatorrhea.  Urination  spermator- 
rhea. Urethrorrhea.  Prostatorrhea.  Confusion  in  terms  of 
various  authors.  Etiology.  Prostatic  massage  a  cause  of 
pollutions.  Results  of  masturbation  a  cause.  Normal  pollu- 
tions. Pathology.  Physiology  of  coitus.  Local  pathology. 
Pathology  of  defecation  spermatorrhea.  Opinions  of  various 
authors.  Author's  opinion.  Pathology  of  urethrorrhea.  Symp- 
toms. Quack  literature.  Pollution  dreams.  Practical  impor- 
tance  of   pollution    dreams.     General    symptoms.     Diagnosis. 


Contents.  xiii 


PAGE 

Prognosis.  Prophylactic  treatment.  General  treatment.  Bro- 
mides. Deep  instillations.  Psychrophore.  Pollutions  in  the 
female    106 


CHAPTER   VIII. 

Priapism. 

Definition.  Etiology.  Priapism  in  children.  Priapism  in  adults. 
Essential  priapism.  Pathology.  Causes  which  act  upon  the 
erection  center.  Causes  which  act  by  removal  of  inhibition. 
Causes  which  act  directly  upon  the  tissues  of  the  penis.  Symp- 
toms. Diagnosis.  Course  and  prognosis.  Treatment.  Clitor- 
ism.     Clitoris  crises.     Differentiation  from  pseudo-crises 137 

CHAPTER   IX. 

Satyriasis. 

Definition.  Increased  sexual  desire  not  satyriasis.  Etiology. 
Theory  of  von  Krafft-Ebing.  Pathology,  Author's  opinion. 
Symptoms.  Chronic  satyriasis.  Diagnosis.  Prognosis.  Treat- 
ment.    Importance  of  treatment 150 

CHAPTER   X. 

Nymphomania. 

Definition.  General  considerations.  Etiology.  Heredity.  Path- 
ology. Symptoms.  Illustrative  cases.  Nymphomania  and 
sterility.     Diagnosis.     Course  and  prognosis.     Treatment..   159 

CHAPTER   XI. 
Frigidity. 

Definition.  Total,  partial,  congenital,  acquired.  Frequency  of  con- 
dition. Frigidity  different  from  lack  of  orgasm.  Etiology 
and  pathology.  Normal  frigidity.  Acquired  frigidity.  Intel- 
lectual frigidity.  Congenital  frigidity.  Heredity.  Pathology. 
Frigidity  and  sterility.  Author's  discussion  on  sexual  pas- 
sion. Symptoms.  External  characteristics  of  frigid  women. 
Diagnosis.  Prognosis.  Treatment.  Necessity  of  instructing 
husband    166 


xiv  Contents. 

CHAPTER   XII. 

Vaginismus.  page 

Definition.  Etiology.  Pathology.  Symptoms.  Penis  captivus. 
Illustrative  cases.  Diagnosis.  Course  and  prognosis.  Vagi- 
nismus and  the  law.  Prophylactic  treatment.  General  treat- 
ment.    Dilatation.     Operation 180 

CHAPTER   XIII. 

Dyspareunia. 

Definition.  German  conception  of  term.  Etiology  and  pathology. 
Symptoms.  Diagnosis.  Prognosis.  Treatment.  Conditions 
akin  to  dyspareunia.  Dyspareunia  in  the  male.  Definition. 
Etiology.  Pathology.  Symptoms.  Diagnosis.  Prognosis. 
Treatment    190 

CHAPTER   XIV. 

Absence  of  Orgasm  in  the  Female  During  Coitus. 

Definition.  Orgasm  not  synonymous  with  voluptuous  feeling.  Ger- 
man definition.  Etiology.  Pathology.  Physiology  of  normal 
coitus  in  the  female.  Symptoms.  Relationship  to  sterility. 
Author's  opinion.     Diagnosis.     Prognosis.     Treatment....   196 

CHAPTER   XV, 

Enuresis, 

Definition.  Classification.  Etiology  and  pathology.  Enuresis  and 
epilepsy.  Symptoms.  Psychic  element.  Diagnosis.  Prognosis. 
Treatment.  "Wonderful  cures."  General  treatment.  Folly  of 
punishment.  Regulation  treatment.  Treatment  of  obstinate 
cases.  Author's  experiments.  Treatment  by  re-education. 
Different  methods  of  treatment  by  various  authors 208 

CHAPTER   XVI. 

The  Evil   Consequences   of  Withdrawal. 

General  considerations.  Importance  to  general  practitioners.  Defi- 
nition. Etiology.  Pathology.  Physiology  of  normal  coitus. 
Pathology  of  withdrawal.  Importance  of  experience  in  pos- 
terior endoscopy.  Effect  of  withdrawal  on  female  organs. 
Ignorance  of  the  male  about  coitus.  Symptoms.  Local  symp- 
toms. Reflex  symptoms.  Illustrative  cases.  Diagnosis.  Course 
and  prognosis.     Treatment 224 


Contents.  xv 

CHAPTER   XVII. 

Continence.  page 

General  considerations.  Importance  to  general  practitioner  and 
every  specialty.  Social  and  economic  considerations.  Pre- 
vention of  spread  of  venereal  disease.  Prophylactic  treatment 
of  venereal  disease.  Chances  of  infection  from  illicit  coitus. 
Abortive  treatment  of  venereal  disease.  Is  continence  physio- 
logical? Views  of  physiologists.  Views  of  various  authors. 
Masturbation  and  continence.  Sexual  perversion  due  to  con- 
tinence. Author's  opinions.  Views  of  neurologists.  Con- 
tinence and  impotence.  Coitus  not  merely  for  purposes  of 
procreation.  Continence  contrary  to  nature.  Author's  deduc- 
tions.   Improvement  in  morality  as  compared  to  the  past.  252 

CHAPTER   XVIII. 
Some   Unusual   Forms   of   Sexual    Neuroses. 

General  considerations.  Illustrative  cases.  Results  of  treatment 
not  due  to  psychic  effects 282 

Bibliography    296 

Index    303 


Disorders  of  the  Sexual  Function, 


belief,  based  upon  an  extended  experience  with  primarily 
normal  individuals,  that  masturbation,  no  matter  how  se- 
verely indulged  in,  never  leads  to  idiocy,  insanity,  nor  sexual 
perversion.  The  disease  is  so  widespread  that  it  is  no 
wonder  that  we  find  such  a  large  percentage  of  masturba- 
tion in  the  histories  of  these  latter  conditions;  nor  can  we 
conclude  from  this  fact  that  the  latter  conditions  were 
caused  by  early  masturbation,  for  we  would  get  the  same 
percentage  in  the  histories  of  perfectly  normal  individuals 
as  well.  I  will  discuss  (i)  masturbation  in  boys  and  girls 
before  adolescence;  (2)  pseudo-masturbation  in  infants; 
(3)  masturbation  in  the  adult  male;  (4)  masturhatio  inter- 
rupia;  (5)  masturhatio  incompleta;  (6)  impotentia  masiur- 
bationis;  (7)  masturbation  in  the  adult  female. 

I.  MASTURBATION  IN  BOYS  AND  GIRLS  BEFORE 
ADOLESCENCE. 

Masturbation  is  not  at  all  uncommon  in  the  very  early 
months  of  childhood,  but  I  believe  that  the  theme  has  been 
much  confused  by  such  authorities  as  Lindner,  Hirschsprung 
and  others,  who  include  under  masturbation  any  state  of 
voluptuous  excitement,  even  when  the  excitement  is  brought 
about  not  by  direct  irritation  of  the  genitals;  and  these 
authors  include  under  this  heading  such  acts  as  sucking 
movements  with  the  lips,  sucking  the  fingers,  picking  the 
nose,  and  many  like  acts.  While  from  a  purely  Freudian 
standpoint  these  acts  may  be  reasoned  out  to  be  sexual  in 
origin,  I  do  not  consider  them  in  the  following  pages  as 
acts  of  masturbation. 


Masturbation  before  Adolescence. 


Etiology. — According  to  Pfandler  and  Schlossmann,^" 
in  cases  occurring  during  the  first  months  or  years  of 
life,  that  is,  before  there  is  even  a  suspicion  of  sexual  feel- 
ing, the  condition  mentioned  is  caused  by  some  organic 
pathological  condition  about  the  genitals.  Very  frequently 
we  find  intertriginous  processes,  especially  about  the  vulva. 
Often,  too,  the  irritation  is  caused  by  worms.  The  pleasur- 
able relief  from  the  itching  which  is  at  first  the  only  result 
of  scratching  or  rubbing  the  vulva,  and  pressing  the  thighs 
together,  soon  engenders  a  habit  which  is  persisted  in  on 
account  of  the  voluptuous  sensation  which  it  excites.  In 
infant  boys,  the  irritation  caused  by  retained  smega  due  to 
a  tight  or  long  prepuce  leads  at  first  to  scratching  for  relief, 
and,  if  the  cause  is  not  removed,  later  to  the  manipulation 
of  the  penis  for  the  newly  discovered  voluptuous  sensation 
produced  thereby.  Sometimes  irresponsible  nurses  quiet 
crying  children  by  titillation  of  the  genitals,  and  thus  start 
the  habit  very  early  in  infancy.  Irritation  caused  by  highly 
acid  urine  may  also  start  the  trouble. 

Jacobi^^  has  long  ago  called  attention  to  the  fact 
that  in  the  young  boy  the  prolonged  handling  of  the  penis 
for  purposes  of  urination  is  in  itself  a  cause  for  the  com- 
mencement of  the  habit.  He  says :  "The  young  child  is 
but  clumsy  and  the  reverse  of  adroit.  It  takes  him  time  to 
disentangle  the  organ.  Frequently  in  the  streets  and  gar- 
dens have  I  seen  sympathizing  little  friends,  mostly  of  the 
other  sex,  and  then  somewhat  older,  or  servants,  busy  with 
rendering  the  required  aid  in  the  emission  of  the  urine." 

In  older  children,  especially  those  that  attend  school, 
certain  exercises  in  which  the  legs  are  frequently  rubbed 


Disorders  of  the  Sexual  Function. 


together  may  be  the  origin,  while  warm  feather  beds  and 
spanking  may  often  be  the  starting  point.  But,  in  a  large 
number  of  cases  that  develop  for  the  first  time  among 
school-children,  the  practice  has  been  actually  taught  them 
by  older  boys;  indeed,  in  some  cases,  the  practice  has  de- 
veloped into  a  veritable  epidemic.  During  school-life,  the 
condition  is  much  more  common  among  boys  than  girls, 
although  by  no  means  uncommon  among  the  latter. 

Pathology. — In  the  vast  majority  of  cases  occurring  at 
this  time,  no  organic  changes  have  as  yet  taken  place,  nor 
has  such  a  vicious  circle  been  produced  as  will  be  presently 
described  as  occurring  in  the  adult  male.  There  is  simply 
a  local  irritation  of  the  genitals  present,  with  as  yet  no  per- 
manent change  in  the  urethral  mucous  membrane.  In  the 
majority  of  cases  at  this  time,  if  the  habit  can  be  abolished 
by  removing  the  local  irritant  which  started  the  trouble, 
and  adding  thereto  moral  suasion  to  be  presently  described, 
everything  returns  to  normal  without  any  special  treatment. 
There  are  some  very  precocious  cases,  however,  that  de- 
velop so  rapidly  as  to  cause,  even  at  this  stage  and  at  this 
early  age,  the  same  local  and  central  irritation  which  is 
found  in  the  confirmed  adult  masturbator.  The  pathology 
of  these  cases,  being  the  same  as  in  the  adult  (only  having 
developed  before  adolescence),  will  be  described  later  on 
under  the  caption  of  Masturbation  in  the  Adult  Male. 

Symptoms. — The  local  symptoms  consist  simply  of  red- 
ness, and  sometimes  a  slight  swelling  of  the  prepuce  in  the 
male,  and  of  the  vulva  in  the  female.  Sometimes  a  slight 
vaginitis  exists  in  the  latter. 

The  general  symptoms  in  very  young  children  are  some- 


Masturbation  before  Adolescence. 


times  very  hard  to  recognize.  In  them  masturbation  con- 
sists mostly  of  thigh  friction  or  of  rubbing  the  genitals 
against  some  article  of  furniture.  Almost  endless  varieties 
of  methods  are  employed  in  the  habit. 

The  symptoms  in  older  children  who  indulge  the  habit 
are  quite  characteristic.  They  are  generally  more  bashful, 
more  retired,  more  dreamy,  more  easily  embarrassed  than 
normal  children.  They  complain  of  headaches,  are  easily 
fatigued,  are  generally  anemic  and  run  down.  They  do  not 
play  with  other  children  and  frequently  avoid  their  society. 
Boys  are  as  a  general  rule  more  cowardly  and  timid,  and 
.are  frequently  praised  by  their  teachers  for  their  quiet  and 
orderly  disposition.  Some  pediatricians  claim  to  have  no- 
ticed cases  of  functional  heart  disease  due  to  masturbation. 

Diagnosis. — In  some  cases  the  diagnosis  is  quite  easy, 
while  in  others,  unless  we  are  on  the  lookout,  the  disease 
is  often  not  suspected  for  a  long  time.  As  in  the  case  of 
so  many  forms  of  sexual  neuroses,  the  patients  do  not  come 
to  us,  saying  that  they  are  suffering  from  sexual  neuroses, 
and  have  such  and  such  symptoms,  but,  on  the  contrary, 
complain  of  the  most  varied  symptoms  {vide  supra)  ;  some- 
times only  headaches,  loss  of  appetite,  and  general  nervous- 
ness, etc.  Often  they  do  not  complain  at  all,  and  this  is  the 
regular  thing  with  very  young  children,  until  the  mother 
notices  something  is  wrong  with  the  child.  Most  of  the 
symptoms  in  such  cases  are  often  thought  to  be  due  to 
errors  in  digestion,  overwork  at  school,  etc.,  without  the 
real  cause  being  suspected.  It  is  of  no  use  to  ask  a  boy 
directly  if  he  masturbates,  as  in  the  vast  majority  of  cases 
he  will  positively  deny  it,  and  it  often  requires  the  greatest 


Disorders  of  the  Sexual  Function. 


tact  on  the  part  of  the  physician  to  get  at  the  truth.  The 
most  important  point  in  the  diagnosis  of  this  condition  is : 
to  bear  in  mind  the  possibiHty  of  such  a  disease  in  all  cases 
of  inexplicable  nervous  or  psychic  symptoms.  Teachers  in 
school  and  parents  also  should  be  taught  to  be  on  their 
guard,  and  should  know  of  the  frequent  existence  of  this 
neurosis  so  as  to  be  able  to  detect  it  at  the  earliest  possible 
moment.  The  physician  should  not  neglect  an  examination 
of  the  genitals  in  any  suspicious  case,  and  very  often  the 
local  symptoms  will  tell  the  tale.  In  young  boys,  after  an 
examination  of  the  genitals  by  the  physician,  whether  he 
finds  anything  there  or  not,  it  is  often  advisable  for  the 
physician,  if  he  is  reasonably  sure  of  his  ground  from  the 
general  symptoms,  to  immediately  tell  the  boy,  after  the 
examination,  that  he  masturbates.  The  boy,  being  taken  off 
his  guard,  if  guilty,  will  imagine  that  the  physician  can  tell 
by  the  examination,  and  will  often  admit  the  truth  at  once. 
Course  and  Prognosis. — The  earlier  the  habit  is  discov- 
ered and  attended  to,  the  easier  it  is  to  cure.  In  very  many 
cases  children  themselves  notice  the  evil  consequences  of 
the  habit  and  stop  it  voluntarily,  without  any  special  treat- 
ment whatever.  But  even  cases  of  very  long  duration  can 
be  cured,  if  not  by  the  method  presently  to  be  described,  by 
the  method  of  treating  adults,  which  they  really  are.  The 
very  fact  that  almost  every  man  or  boy  has  at  one  time  or 
another  masturbated  for  varying  lengths  of  time,  and  that 
we  can  get  a  history  of  masturbation  in  almost  every  nor- 
mal person,  even  among  the  great  geniuses  of  the  world, 
shows  that  it  is  not  the  terrible  disease  which  quacks  find  it 
to  their  interest  to  make  it  out  to  be.    At  the  same  time,  it 


Masturbation  before  Adolescence.  7 

is  sufficiently  serious  to  command  the  earnest  attention  of 
every  conscientious  physician  and  teacher.  While  under  its 
baneful  influence,  the  entire  psychical  and  physical  condition 
of  the  child  suffers.  He  can  attend  to  his  lessons,  but  does 
so  under  a  greater  amount  of  nervous  tension  and  energy. 
And  so,  while  recognizing  that  it  is  a  curable  disease,  and 
a  very  common  disease,  and  that,  in  the  vast  num.ber  of 
cases,  it  leaves  no  permanent  bad  results,  we  should  never- 
theless not  consider  it  beneath  our  dignity  to  treat  it,  if  for 
no  other  reason  than  to  keep  the  child  away  from  the  bane- 
ful influences  of  quack  physicians,  and  because  of  the  ex- 
treme importance  of  early  recognition  and  treatment,  so 
that  the, child  can  develop  both  physically,  mentally,  and 
psychically  with  the  least  expenditure  of  nerve  energy. 

Treatment,  Prophylactic. — Parents  should  be  very  care- 
ful to  remove  anything  or  any  cause  which  might  produce 
irritation  of  the  genital  regions,  or  which  might  create  a 
tendency  for  the  children  to  handle  these  parts.  A  tight 
prepuce  should  either  be  loosened  or  circumcision  be  per- 
formed. A  long  prepuce  should  be  removed  either  entirely 
or  partially.  Worms  and  intertriginous  processes  about  the 
genitals  should  be  removed  and  cured.  Boys  should  not  be 
allowed  to  associate  with  much  older  boys,  for  fear  of  being 
taught  the  habit.  According  to  German  authorities,  boys 
in  school  should  always  have  their  hands  on  the  desk  or 
otherwise  exposed  to  the  view  of  the  teacher,  so  as  to  give 
them  as  little  opportunity  as  possible  to  handle  their  geni- 
tals. They  also  recommend,  on  this  account,  that  young 
boys'  trousers  should  be  made  without  side  pockets,  as  these 
pockets  are  frequently  used  by  boys  for  purposes  of  mas- 


Disorders  of  the  Sexual  Function. 


turbation.  Gymnastic  exercises  in  which  friction  of  the 
thighs  might  frequently  occur  should  be  avoided.  Parents 
should  be  careful  in  the  employment  of  nurses,  as  unscrupu- 
lous nurses  often  employ  this  method  to  quiet  the  children. 
Children  should  not  indulge  in  tea  or  coffee,  and  alcoholics 
are  to  be  particularly  avoided.  Older  boys  should  be  in- 
structed to  empty  the  bladder  before  retiring,  not  to  sleep 
with  too  many  covers  on,  and  to  rise  early  and  empty  the 
bladder  at  once.  For,  sometimes  even  at  this  early  age,  a 
distended  bladder  and  warm  bed-coverings  may  cause  an 
early  erection. 

General  Treatment  for  the  Disease. — The  first  thing  to 
do  is  to  search  for  and  remove  the  cause  w^hich  started  the 
trouble.  It  is  not  necessary  to  repeat  the  various  etiologi- 
cal factors,  as  they  have  been  mentioned  in  the  etiology. 
The  prophylactic  treatment  just  outlined  is  even  of  more 
importence  when  the  habit  has  already  been  indulged  in, 
and  should  be  strictly  adhered  to.  In  very  many  cases, 
especially  if  the  habit  has  just  been  commenced,  the  mere 
removal  of  the  cause  of  the  genital  irritation,  together  with 
the  prophylactic  treatment,  is  sufficient  for  a  cure.  Spank- 
ing is  especially  to  be  avoided,  as  in  some  children  the  act 
of  spanking  arouses  erotic  impressions.  Older  boys  should 
be  spoken  to  in  very  plain  but  tactful  language,  and  their 
sense  of  manhood  be  appealed  to.  The  object  of  treatment 
is  to  direct  the  child's  interest  into  other  and  more  natural 
channels.  At  this  time  the  parent  should  obtain  the  child's 
confidence  and  every  method  be  employed  to  strengthen  his 
will-power  and  help  him  break  the  habit  himself. 

It  is  of  very  little  use  to  try  to  treat  the  patient  by  em- 


Masturbation  before  Adolescence. 


ploying  some  one  to  watch  him  continually;  I  believe  the 
method  is,  in  reality,  harmful.  The  methods  employed  by 
the  masturbator  are  so  numerous,  and  the  opportunities  for 
committing  the  act  so  easy,  that  no  matter  how  careful  the 
watching,  it  will  be  of  no  avail.  I  have  had  under  treat- 
ment a  young  boy  of  exceedingly  wealthy  parentage.  Be- 
fore he  was  sent  to  me  the  parents  had  employed  two  male 
nurses  who  were  with  him  both  day  and  night,  who  went 
with  him,  even  when  he  had  to  go  to  the  toilet,  and  yet  the 
boy  boasted  to  me  that  he  could  masturbate  while  both 
nurses  were  watching  him.  The  little  fellow,  when  he  came 
under  my  care,  was  already  a  confirmed  masturbator,  in 
whom  the  pathological  processes  had  already  advanced  to 
the  same  degree  as  that  which  we  find  in  the  adult  male, 
to  be  presently  described,  and  he  was  treated  in  the  same 
way  as  an  adult,  and  was  cured  and  remained  cured  by  the 
method  to  be  described  later  on  under  that  caption.  I 
believe  constant  watching  not  only  useless  but  harmful,  be- 
cause it  constantly  keeps  the  boy's  mind  reminded  of  his 
genitals.  Every  time  he  sees  his  watcher  he  thinks  of  his 
sexual  apparatus,  and  that  is  the  very  worst  thing  for  him. 
Besides  this  it  lessens  his  will-power,  and  is  almost  an  in- 
citive  to  see  if  he  can  be  shrewd  enough  to  deceive  his 
guardian. 

Except  in  very  exceptional  cases,  I  do  not  believe  in 
restraining  apparatus.  In  some  cases  they  have  done  good, 
but  in  the  vast  majority  of  cases  they  not  only  do  no  good 
but  positive  harm.  In  the  first  place  they  also  concentrate 
the  child's  attention  on  his  genitals,  but,  and  what  is  even 
more  important,  they  stimulate  the  child's  inventive  genius 


10  Disorders  of  the  Sexual  Function. 

in  many  cases,  to  substitute  one  form  of  masturbation  for 
another.  Thus,  boys  who  have  been  masturbating  by 
manipulating  their  genitals  with  their  hands,  and  who  have 
their  hands  tied  together,  or  so  tied  that  they  cannot  reach 
their  genitals,  very  often  invent  a  method  of  masturbating 
in  which  the  hands  can  be  dispensed  with,  such  as  thigh 
friction,  pillow  masturbation,  etc.  Such  method  of  treat- 
ment may  even  be  the  starting  point  for  psychic  masturba- 
tion. There  have  also  been  reported  severe  injury  not  only 
to  the  skin,  but  even  to  the  genital  organs,  from  either  badly 
fitted  restraining  apparatus  or  from  the  effort  of  the  patient 
to  masturbate  with  the  harness  on.  In  short,  except  for 
the  very  bad  cases,  the  best  method  of  treatment  is,  first 
to  remove  the  cause  of  the  local  irritation,  and  then  to  ap- 
peal to  the  child's  will-power  and  manhood,  with  a  full  and 
tactful  explanation  of  the  trouble.  At  the  same  time,  the 
child's  general  health  should  be  improved  by  tonics  and 
well-directed  outdoor  exercises,  and  an  effort  should  be 
made  to  direct  the  child's  mind  into  other  and  more  natural 
channels  by  finding  objects  of  special  interest.  The  bad 
cases,  the  young  boys  who  are  confirmed  masturbators,  are 
really  precocious  in  this  respect,  and,  as  regards  their  sex- 
ual and  psychic  make-up,  are  actually  adults,  having  the 
same  pathology  as  adults  and  are  to  be  treated  as  such. 

II.  PSEUDO-MASTURBATION  IN  INFANTS. 

Rachford,^^  in  his  Presidential  Address  before  the 
Nineteenth  Annual  Meeting  of  the  American  Pediatric 
Society,  calls  attention  to  a  condition  which  he  calls  "pseudo- 
masturbation  in  infants."     He  says  that  it  has  been  pre- 


Pseudo-Masturbation  in  Infants,  11 

viously  described  under  the  titles  of  "Thigh  Friction"  and 
also  "Infantile  Masturbation,"  and  describes  it  as  follows : — 

"It  is  commonly  accomplished  with  the  child  lying  on 
its  back;  the  thighs  are  flexed,  crossed  and  pressed  tightly 
together,  closely  embracing  the  external  genitalia;  in  this 
position  the  infant  makes  a  wriggling  or  up-and-down  body 
movement  and  rubs  its  thighs  together.  In  other  instances 
the  genitalia  are  rubbed  with  the  hands  or  feet  or  against 
some  piece  of  furniture  or  other  foreign  object.  These  move- 
ments are  apparently  attended  by  a  pleasurable  excitement ; 
the  face  is  flushed  and  there  is  a  marked  increase  in  the 
general  nervous  tension.  Following  this  act,  which  con- 
tinues for  a  few  minutes  only,  there  is  a  general  relaxation, 
accompanied  by  mild  perspiration,  quiet  contentment  and,  in 
some  instances,  sleep." 

The  etiological  factors  are  exactly  the  same  as  in  true 
masturbation;  the  treatment  is  exactly  the  same;  it  takes 
about  two  years  to  cure  the  child  of  the  habit,  and  in  some 
exceptional  cases  the  disease  runs  into  true  masturbation. 

The  author  lays  stress  upon  the  point  that  while  the 
external  genitals,  as  well  as  the  bladder  and  rectum,  are 
almost  fully  developed  at  birth,  the  internal  genitals,  espe- 
cially the  uterus  and  ovaries,  are  almost  rudimentary  and 
do  not  undergo  any  development  till  about  the  tenth  year. 
From  this  he  argues  that  there  can  be  no  real  masturbation, 
except  in  exceptional  cases  (which  he  reports)  during  the 
early  years  of  infancy. 

I  confess,  however,  that  I  cannot  at  all  agree  with  this 
author.  Any  one  reading  the  above  description  in  connec- 
tion with  an  older  child,  would  unhesitatingly  pronounce  it 


12  Disorders  of  the  Sexual  Function. 

to  be  masturbation  pure  and  simple.  The  fact  that  a  child 
may  be  cured  of  this  habit  during  infancy,  and  then  later 
on,  through  a  repetition  of  the  same  or  similar  causes,  or 
through  bad  companions  again  contract  the  vice,  is  by  no 
means  an  argument  that  the  first  condition  wiis  not  a  true 
case  of  masturbation.  The  sexual  sense  is  not  entirely  de- 
pendent upon  the  internal  genital  organs,  and  the  fact  that 
these  organs  lie  apparently  dormant  for  about  ten  years, 
is  no  proof  whatever  that  they  may  not  be  exerting  through 
some  internal  secretion,  perhaps,  an  influence  on  the  sexual 
sense.  The  modern  theories  of  Freud  and  his  followers 
seem  to  show  that  the  sexual  sense  is  not  by  any  means 
absent  in  young  children.  Furthermore,  I  can  see  no  use 
in  further  complicating  the  nosology  of  the  subject,  by  in- 
venting a  special  disease,  and  calling  it  pseudo-masturba- 
tion instead  of  masturbation,  particularly  if  it  has  the  same 
etiology,  the  same  symptoms,  the  same  treatment  and  the 
same  prognosis  as  the  condition  we  all  recognize  as 
masturbation. 


CHAPTER  II. 
III.  MASTURBATION  IN  THE  ADULT  MALE. 

General  considerations.  Pathology.  Psychic  masturbation.  Symp- 
toms. Exaggerations  of  many  authors.  Fallacies  in  taking  histories. 
Importance  of  ruling  out  other  conditions.  Masturbation  in  married 
men.  Course  and  prognosis.  Illicit  intercourse  not  a  cure  for  mastur- 
bation. Treatment.  Importance  of  gentle  massage.  Conclusions. 
Masturbatio  interrupta.  Masturbatio  incompleta.  Impotentia  mastur- 
bationis. 

It  is  a  pity  that  this  subject  is  made  so  much  of  by  the 
medical  quacks  and  their  advertising  literature,  and  so  little 
attention  paid  to  it  by  the  regular  physician.  "Of  what 
use,"  says  Vecki,^'^  "to  a  man  who  suffers  from  weak- 
ening pollutions  is  a  physician,  who,  following  the  example 
of  renowned  clinicians,  laughs  at  him  and  sends  him  home, 
with  some  insignificant  and  useless  prescription?"  The 
same  may  be  said  of  masturbation.  It  is  no  wonder  that 
the  patients  go  to  the  quacks,  when  the  average  physician 
does  not  care  to  bother  w4th  him  or  always  treats  the  con- 
dition as  a  mere  neurosis.  I  know  of  one  physician  who 
sends  his  patients  to  the  mountains  for  masturbation,  treat- 
ing it  as  a  neurotic  condition.  At  the  other  extreme,  I  have 
spoken  to  the  head  keeper  (not  a  physician)  of  one  of  our 
largest  public  reformatories,  who  told  me  that  he  "treated" 
this  condition  by  placing  the  culprit  in  a  dark  cell  for  a  week, 
where,  besides  the  total  absence  of  light,  he  receives  only 
one  meal  in  the  twenty-four  hours,  consisting  of  a  loaf  of 
bread  and  a  pitcher  of  water.     "But  so  bad  are  the  boys," 

(13) 


1-i  Disorders  of  the  Sexual  Function. 

he  added,  "that  even  this  treatment  does  not  cure  them." 
Comment  is  unnecessary. 

There  is  still  another  and  very  important  reason  why 
the  subject  of  masturbation  should  be  thoroughly  discussed 
and  understood.  Many  a  young  man  enters  into  illicit  con- 
nection and  becomes  infected  with  venereal  disease,  because 
he  believes  that  coitus  is  the  only  relief  for  masturbation. 
There  are  physicians  who  advise  "careful"  coitus  to  pa- 
tients who  masturbate,  and  there  are  also  physicians  who 
advise  patients  who,  on  account  of  religious  or  other 
scruples,  do  not  wish  to  violate  the  Seventh  Commandment, 
and  who  have,  however,  strong  sexual  feeling,  to  relieve 
themselves  by  masturbation. 

I  have  elsewhere^*  given  my  views  and  discussed  the 
relationship  between  masturbation  and  illicit  coitus.  In 
addition  to  the  many  authors  cited,  I  will  mention  one  more 
author  as  an  example  of  some  medical  advice  which  is  very 
common.  Vecki^^^  says:  "In  the  treatment  of  Onan- 
ism the  individual  has  to  be  carefully  studied ;  not  every 
child,  nor  youth,  nor  even  man,  has  sufficient  will-power  to 
combat  successfully  this  evil  so  difficult  to  conquer.  In 
many  cases  the  object  will  be  attained  by  incessant  watch- 
ing, or  ultimately  by  the  application  of  a  suitable  preventive 
apparatus,  which  the  child  must  wear  day  and  night. 
Mature  individuals  should  be  advised  to  satisfy  the  sexual 
instinct  in  a  natural  way,  and  no  notice  must  be  taken  of 
the  cry  of  horror  uttered  by  pharisaical  medical  authorities 
or  by  those  who,  although  possessed  of  great  scholarship, 
are  nevertheless  destitute  of  experience.  The  notion  that 
whoever  has  once  enjoyed  natural  copulation  will  not  feel 


Masturbation  in  the  Adult  Male.  15 

tempted  to  return  to  Onanism  is  an  error  that  is  somewhat 
prevalent.  Only  copulation  that  is  practised  regularly, 
satisfying  every  strong  and  real  desire,  can  cure  Onanism; 
while  copulation  enjoyed  at  long  intervals  only  would  rather 
incite  to  more  frequent  Onanism,  because  pleasing  recollec- 
tions are  near  at  hand." 

This  is  certainly  a  very  pleasing  way  of  treating  Onan- 
ism and  ought  to  be  popular ;  in  addition,  it  ought  to  bring 
to  the  adviser  not  only  many  cases  of  Onanism,  but  also 
many  cases  of  gonorrhea  and  syphilis  as  well. 

With  very  few  exceptions,  masturbation  is  not  a  nervous 
disease.  It  is  not  a  disease  of  the  imagination.  It  is  a  real 
disease,  and  no  amount  of  talking,  whipping,  or  laughing 
will  cure  it.  Those  who  say  that  the  patient  should  be 
talked  to,  and  his  will-power  and  self-restraint  cultivated, 
his  general  health  improved  by  tonics,  outdoor  sports,  etc., 
have  very  little  experience  with  this  disease.  When  mas- 
turbation has  been  firmly  established  you  can  no  more  talk 
your  patient  out  of  masturbating  than  you  can  talk  a  child 
suffering  from  scabies  out  of  scratching.  The  latter  is 
caused  by  an  irritation  in  the  skin  and  the  former  by  an 
irritation  in  the  prostatic  urethra.  On  the  other  hand,  so 
definite  is  the  disease,  so  specific  is  the  treatment,  and  so 
positive  is  the  cure,  that  it  is  not  even  necessary  to  obtain 
the  patient's  confidence  or  co-operation,  from  a  purely 
therapeutical  point  of  view.  In  the  treatment  of  the  disease 
no  demands  are  made  upon  the  patient's  will-power  or  self- 
restraint,  because  we  recognize  that  the  patient  has  little 
say  in  the  matter;  it  is  not  a  question  of  self-control. 
Also,  the  application  of  restraining  apparatus  is  worse  than 


16  Disorders  of  the  Sexual  Function. 

useless,  for  in  the  first  place  it  concentrates  the  patient's 
mind  on  his  genitals,  and,  in  the  second  place,  to  return  to 
our  comparison  with  the  child  suffering  from  scabies,  this 
method  of  treatment  would  be  similar  to  tying  the  hands 
together  of  such  a  child  to  prevent  it  from  scratching.  It 
would  not  scratch,  not  because  it  has  been  cured  of  its 
scabies,  but  because  it  is  mechanically  prevented  from  so 
doing.  In  treating  this  disease  we  should  recognize  that 
we  have  a  definite  pathological  condition  to  treat,  and  not 
an  imaginary  disease,  and  the  treatment  should  be  under- 
taken in  the  same  spirit  as  that  of  a  surgeon  when  he  under- 
takes the  treatment  of  a  fracture  in  an  otherwise  healthy 
person;  if  he  gets  the  fragments  in  correct  apposition  and 
keeps  them  so  by  plaster-of-Paris  or  other  splint  for  the 
necessary  time,  that  bone  will  knit  and  the  limb  become 
normal,  whether  the  patient  has  confidence  in  the  treatment 
or  not. 

Pathology. — The  pathology  of  masturbation  is  quite 
simple  and  directly  in  harmony  with  the  prognosis  and  treat- 
ment. It  shows  that  there  is  no  new  element  introduced, 
but  that  it  is  simply  an  exaggeration  of  a  perfectly  normal 
process.  As  pointed  out  by  Bangs,^  with  every  irritation 
of  the  urethra,  there  is  a  corresponding  irritation  of  a  cer- 
tain portion  of  the  brain,  which  irritation  excites  the  per- 
son to  increased  sexual  desire ;  this  increased  sexual  desire 
leads  to  masturbation  and  further  increases  the  local  hyper- 
esthesia in  the  deep  urethra.  A  vicious  circle  is  thus  formed. 
We  thus  see  that  the  entire  pathology  is  essentially  and  in 
the  beginning  but  an  exaggeration  of  what  takes  place  in 
normal  sexual  intercourse.     At  the  beginning,  the  child 


Masturhation  in  the  Adult  Male.  17 

manipulates  his  penis ;  this  act  sends  an  impulse  to  his  brain, 
which  sends  another  impulse  to  his  muscles  of  erection,  etc., 
and  also  causes  a  congestion  of  the  deep  (prostatic)  urethra. 
So  far  the  condition  is  like  normal  coitus.  But  this  act 
frequently,  repeated  leads  to  a  hyperesthesia  of  the  prosta- 
tic urethra,  so  that  impulses  are  constantly  sent  to  his  brain, 
which  again  in  response  sends  impulses  to  the  prostatic 
urethra,  still  further  increasing  its  hyperesthesia,  and  thus 
the  vicious  circle  is  formed.  In  other  words,  there  is  in 
time  formed  such  an  irritation  in  the  deep  urethra  that  the 
patient  is  compelled  to  masturbate.  The  difference  between 
masturbation  and  normal  coitus  is,  in  the  first  place,  that  it 
is  initiated  in  the  young  person  at  or  even  before  puberty, 
when  the  sexual  apparatus  is  still  in  an  imperfect  and  de- 
velopmental state,  when  the  brain-cells  appertaining  to  this 
function  are  also  being  developed,  are  immature  and  more 
irritable  and,  in  short,  when  the  whole  body  is  undergoing 
profound  chemical,  physical,  and  psychological  changes,  and 
in  the  second  place  that  the  act  is  repeated  much  more  fre- 
quently than  normal  coitus  could  be.  It  is  this  combination 
that  causes  the  dire  results.  Even  if  a  normal  adult  with 
fully  developed  normal  sexual  organs  were  to  attem^pt  coitus 
as  often  as  some  of  these  children  masturbate,  the  result 
would  also  be  a  final  inability  to  perform  the  act ;  but  when 
we  consider  that  the  act  is  accomplished  with  immature  and 
undeveloped  organs,  with  an  overirritable  brain,  and  at  a 
time  when  all  the  energy  is  needed  for  body  development 
not  only  in  this  particular  field,  but  in  every  function  of  the 
body,  we  can  easily  understand  why  the  results  are  so  pro- 
found. We  can  also  understand  how  a  dose  or  large  amount 


18  Disorders  of  the  Sexual  Function. 

of  bromides  cannot  cure  the  trouble,  as  it  begins  at  the 
wrong  end.  It  does  not  cure  the  hyperesthesia  of  the  pros- 
tatic urethra,  but  simply  dulls  the  brain-cells,  so  that  they 
cannot  receive  impressions  from  the  deep  urethra.  It  is 
analogous  to  dosing  a  child  suffering  from  scabies  so  that 
it  cannot  feel  the  bites  of  the  insect  and  is  thus  less  liable 
to  scratch.  As  long  as  the  insect  is  not  removed,  we  have 
not  cured  our  patient,  even  if  we  prevent  it  from  scratching. 
We  can  also  see  how  useless  it  is  to  appeal  to  his  self-con- 
trol. It  must  be  understood  that  in  this  chapter  I  am  only 
referring  to  the  adult  confirmed  masturbator.  It  is  true 
that  at  the  beginning,  when  the  child  first  begins  to  mastur- 
bate and  before  there  has  been  formed  the  hyperesthesia  of 
the  prostatic  urethra,  the  child  can  be  coaxed  to  stop  the 
habit ;  but  in  the  adult,  when  there  has  already  been  formed 
the  vicious  circle  above  referred  to,  with  the  marked  hyper- 
esthesia of  the  prostatic  urethra,  no  amount  of  self-control 
can  have  any  effect  upon  this  hyperesthesia,  just  as  no 
amount  of  self-control  can  remove  Acarus  scahiei  from  the 
scabietic.  We  can  also  see  why  coitus  cannot  cure  the  con- 
firmed masturbator.  Masturbation  being  due  to  a  conges- 
tion of  the  prostatic  urethra,  anything  that  increases  the 
congestion  must  be  harmful.  This  fact  I  have  often  noticed 
clinically, — that  many  of  these  patients  who  attempt  coitus, 
even  if  successful  in  the  performance  of  the  sexual  act,  still 
continue  to  masturbate.  Even  Vecki  (131),  who  is  one  of 
the  strongest  opponents  to  the  idea  of  continence  in  young 
men,  has  stumbled  on  the  truth,  and  In  an  extract  already 
quoted  is  forced  to  admit  that  in  his  experience  masturba- 
tion cannot  be  cured  by  coitus. 


Masturbation  in  the  Adult  Male.  19 

In  psychic  masturbation,  the  pathology  is  as  follows: 
Either  as  a  result  of  previous  or  recent  experience,  an  im- 
pulse is  sent  from  the  higher  parts  of  the  brain  to  the  sexual 
centers.  These  in  turn  send  impulses  to  the  vessels  and 
glands  of  the  genitals  just  as  in  normal  coitus  or  ordinary 
masturbation.  If  this  is  frequently  repeated  not  only  do 
the  sexual  centers,  which  have  not  had  a  chance  to  return 
to  a  physiological  rest  as  in  normal  coitus,  become  hyperir- 
ritated,  but  the  genitals  themselves  remain  hyperemic.  This 
has  been  definitely  demonstrated  in  the  male,  where  hyper- 
emia and  congestion  of  the  posterior  urethra  have  been  seen 
by  Frank  through  the  posterior  urethroscope  in  pure  cases 
of  psychic  masturbation.  As  a  result  of  the  hyperirritated 
condition  of  the  sexual  centers,  and  the  local  chronic  con- 
gestion of  the  genitals,  a  vicious  circle  is  set  up,  and  the 
habit  is  more  and  more  Indulged  in.  Later  on  the  sexual 
centers  become  more  and  more  exhausted  and  it  takes 
stronger  and  stronger  mental  images  to  arouse  them  into  ac- 
tivity. The  nervous  drain  upon  the  higher  centers  can  easily 
be  imagined.  The  above  pathology  of  psychic  masturbation 
applies  alike  to  males  and  females,  to  adults  and  adolescents. 

Blum^^  says :  "The  mastubatory  act  supposes  a 
much  greater  activity  of  the  imagination;  the  immediate 
erotic  impressions  and  sensations,  which  come  spontane- 
ously in  coitus,  must  be  replaced  in  masturbation  by  in- 
creased mechanical  stimuli  and  by  excessive  demands  upon 
the  erotic  conceptions.  All  these  powerful  accessories  to 
sexual  activity,  which  we  receive  in  normal  cohabitation 
from  visual  impressions,  tactile  sensations,  kissing,  sensa- 
tions of  smell  (perfume)  and  of  hearing,  all  these  immedi- 


20  Disorders  of  the  Sexual  Function. 

ate  perceptions  must  be  replaced  with  the  manual  mastur- 
bator  by  the  power  of  the  imagination — truly  an  excess  of 
mental  effort,  a  waste  of  valuable  nervous  substance." 

Symptoms.  — As  stated  before,  it  is  a  pity  that  because 
so  many  medical  qviacks  have,  for  their  own  personal  inter- 
est, so  exaggerated  the  symptoms  of  masturbation  in  the 
'literature"  which  they  scatter  broadcast,  many  regular 
physicians  consider  themselves  bound,  in  order  to  offset  this 
bad  influence,  to  deny  any  importance  to  the  subject,  which 
seems  to  have  just  the  opposite  effect  on  the  patient, — to 
wit,  it  has  the  tendency  to  drive  the  patient  to  the  very 
quacks  who  ought  to  be  avoided. 

In  giving  the  symptoms  of  masturbation  it  is  hard  to 
take  the  middle  course  and  avoid  the  exaggerations  of  the 
quack  on  the  one  hand  and  the  indifference  of  many  physi- 
cians on  the  other.  There  are  some  physicians,  however, 
especially  among  the  Germans,  who  seem  to  be  so  carried 
away  with  the  importance  of  the  subject,  that  in  their  enthu- 
siasm they  outdo  the  quacks!  and  refer  every  ailment  under 
the  sun  to  the  evil  results  of  masturbation.  Listen,  for 
instance,  to  Steinbacher,^^^  who  gives  in  his  work  as 
the  results  of  masturbation  the  following  ailments :  Insan- 
ity, blindness,  indigestion,  melancholia,  hyperchondriasis, 
squint,  sleeplessness,  headache,  dizziness,  itching,  abnorm- 
ities in  the  senses  of  taste  and  smell,  stuttering,  angina 
pectoris,  palpitation  of  the  heart,  a  dry  cough  that  may  be 
mistaken  for  tuberculosis,  asthma,  pains  in  the  feet,  knees 
and  hands,  epilepsy,  chorea,  spasms  or  paralysis  of  the 
muscles  of  the  bladder,  impotence,  etc. 

Those  who  have  studied  the  subject  from  every  possible 


Masturbation  in  the  'Adult  Male.  21 

point  of  view  can  understand  how  a  reputable  physician 
and  an  author  can  obtain  this  long  list  of  dire  complaints  as  a 
sequence  to  masturbation.  I  have  elsewhere^"*  already 
pointed  out  the  mistakes  in  these  authors,  but  this  particular 
point  is  so  important  that  I  may  be  pardoned  for  repeating 
it  here.  Masturbation  is  so  very  common  in  early  childhood 
that  if  we  take,  for  instance,  the  histories  of  a  large  number 
of  cases  of  insanity  or  chorea,  or  almost  any  other  trouble, 
we  shall  find  a  very  large  percentage  of  early  masturbation, 
but  this  by  no  means  indicates  that  masturbation  per  se  was 
the  cause  of  insanity,  etc.  It  is  in  this  way  that  enthusiasts 
allow  themselves  to  be  betrayed  into  blaming  every  defect 
on  masturbation.  I  am  certain  that  if  w^e  were  to  take  the 
histories  of  lOO  of  the  greatest  geniuses  we  would  find  in 
over  90  per  cent,  of  them  a  history  of  masturbation. 

Again,  in  taking  the  histories  of  these  cases  there  is 
still  another  error  which  we  must  be  careful  to  avoid.  We 
must  not  suggest  any  symptom,  but  allow  the  patient  to  tell 
his  own  story  without  interruption.  We  will  then  often 
find  that  he  repeats  them  by  rote  as  he  has  read  them  either 
in  the  advertisement  of  some  quack  in  public  newspapers, 
or  from  one  of  the  many  books  that  are  so  freely  distribu- 
ted in  the  city.  It  will  therefore  be  evident  that  the  symp- 
toms just  heard  in  such  a  case  cannot  scientifically  be  put 
down  as  the  symptoms  of  masturbation,  and  it  is  to  detect 
this  possible  source  of  error  that  I  never  interrupt  my  pa- 
tient, so  that  I  may  be  able  to  recognize  the  symptoms 
suggested  by  what  he  has  been  reading. 

After  deducting  all  these  exaggerations  and  sources  of 
error,  we  will  still  have  certain  symptoms  and  conditions 


22  Disorders  of  the  Sexual  Function. 

and  sequelae  of  masturbation  which  are  genuine  and  real, 
and  not  the  result  of  imagination  or  suggestion.  I  cannot 
help  repeating  here  that  the  symptoms  and  sequelae  of  mas- 
turbation actually  exist,  and  it  is  harmful  to  imagine  that 
they  can  be  talked  out  of  the  patient  and  are  only  imaginary. 
I  shall  now  attempt  to  describe  them  calmly  and  without 
exaggeration  as  I  have  actually  seen  them  in  my  clinics  and 
in  private  practice. 

The  patient,  as  before  stated,  according  to  our  arrange- 
ment is  first  seen  by  the  neurologist.  It  is  significant  in 
itself  that  he  picks  out  the  neurological  rather  than  the 
genitourinary  clinic.  He  presents  himself  complaining  of 
various  nervous  symptoms,  very  often  not  knowing  or  sus- 
pecting what  the  cause  is.  Doctor  Abrahamson  informs 
me  that  the  symptoms  which  make  him  suspect,  in  the  ab- 
sence of  other  causes,  masturbation  as  the  etiological  factor, 
are  those  of  cerebal  exhaustion, — to  wit,  delayed  or  at  times 
incoherent  associations;  difHculty  in  recalling  names  or 
things;  inability  to  express  themselves  as  well  as  before; 
frequent  loss  of  the  thread  of  thought,  and  incapability  of 
continued  effort.  The  feeling  tone  is  changed  and  they  are 
disagreeably  affected  by  slight  and  insufficient  causes.. 

The  most  prominent  of  these  is  loss  of  memory.  There 
are  few  masturbators  who,  if  they  complain  at  all,  do  not 
complain  of  it.  I  have  often  made  a  psychic  investigation 
of  this  very  common  symptom  and  have  come  to  the  con- 
clusion that,  strictly  speaking,  there  is  really  no  loss  of 
memory  whatsoever,  but  that  the  events  are  crowded  out 
of  the  brain  by  the  day-dreams  or  self-consciousness  of  the 
patient.     The  masturbator  is  essentially  a  dreamer,  and  in 


Masturbation  in  the  Adult  Male.  23 

using  this  term  I  do  not  at  all  wish  to  use  it  in  the  spirit 
that  the  term  "dreamer"  is  often  used;  I  do  not  mean  the 
word  "dreamer"  as  it  is  often  applied  to  men  of  great  ideals, 
but  I  mean  it  in  its  literal  sense.  The  masturbator  is  shy 
and  bashful,  exceedingly  self-conscious ;  he  thinks  everyone 
can  read  his  condition,  becomes  a  recluse,  and  he  compen- 
sates for  the  loss  of  outside  society  by  self-communion, — 
in  other  words,  by  day-dreams.  This  introspection  absorbs 
his  entire  attention,  and  outside  events  pass  him  by  hardly 
noticed,  or  receive  slight  attention.  It  is  for  this  reason 
that  he  thinks  his  memory  at  fault,  but  the  real  reason  is, 
not  that  he  forgets,  but  that  he  does  not  observe,  or  pays 
too  little  attention  to  things  outside  of  his  self-thoughts. 
That  there  is  no  real  loss  of  memory  is  proved  by  the  fact 
that  the  masturbator  can  remember  if  hei  wants  to.  I  have 
had  many  cases  of  masturbation  among  college  students  and 
upon  inquiry  have  found  that  they  rank  just  as  high  in  their 
work  as  the  average, — in  fact,  some  have  received  honors 
and  prizes  for  their  work,  whereas  if  there  were  any  loss  or 
serious  impairment  of  memory  they  could  not  have  got 
along  at  all.  As  a  matter  of  fact,  masturbation  is  not  in- 
compatible with  great  genius. 

Another  symptom  that  many  complain  of  is  pain  or 
weakness  in  the  muscles  of  the  thigh  and  legs.  Still  another 
common  symptom  is  pain  in  the  eyes,  also  headache  and  di^- 
ziness.  One  must  be  careful  to  interpret  these  symptoms 
correctly,  or  else  harm  may  be  done.  For  instance,  while 
there  are  very  many  masturbators  who  complain  of  eye 
pains  and  dizziness,  so  that  these  can  often  be  ascribed  to 
the  disease  under  consideration,   we  must  not  so  ascribe 


2i  Disorders  of  the  Sexual  Function. 

them,  in  any  individual  case,  until  the  eyes  have  been  ex- 
amined by  a  competent  ophthalmologist  to  exclude  errors  of 
refraction.  And  so  it  is  with  all  the  symptoms  complained 
of ;  before  we  blame  them  on  masturbation  we  must  be  cer- 
tain that  there  is  not  a  more  real  organic  basis  for  them.  As 
stated  before,  it  is  just  a  neglect  of  this  precaution  that 
leads  writers  into  the  error  of  ascribing  a  long  list  of  ills 
to  masturbation.  It  must  be  remembered  that  the  mastur- 
bator  is  exceedingly  introspective  and  likes  to  blame  every 
trouble  he  has  on  his.  "youthful  sin."  If  he  is  constipated, 
or  has  distress  after  eating  or  anything  else,  he  is  sure  to 
blame  it  on  masturbation. 

Coming  now  to  the  symptoms  of  the  genitourinary  tract, 
we  find  first  and  foremost  a  marked  hyperesthesia  of  the 
entire  urethra,  and  especially  of  the  prostatic  portion.  This 
condition  is  always  present  and  is  almost  pathognomonic 
of  masturbation.  I  have  in  the  course  of  many  genitouri- 
nary examinations  examined  many  urethrae,  but  in  no  con- 
dition of  the  urethra,  whether  due  to  the  presence  of  a 
foreign  body,  to  the  irritation  of  a  very  strong  injection,  to 
a  tight  stricture  or  what  not,  is  the  sensitiveness  as  evinced 
by  the  pain  it  caused  to  be  at  all  compared  to  that  which 
we  find  in  the  chronic  masturbator.  This  sensitiveness  is 
very  important  not  only  from  a  symptomatic  point  of  view, 
but  also  from  a  therapeutic  and  prognostic  point.  The  sen- 
sitiveness is  our  most  important  guide  to  the  frequency  of 
treatment,  to  the  strength  of  solution  to  be  used,  and  also 
to  the  cognizance  of  cure  or  cessation  of  all  treatment. 

Hand  in  hand  with  this  hyperesthesia  of  the  urethra,  and 
dependent  upon  the  same  cause  is  the  hyperesthesia  of  the 


Masturbation  in  the  Adult  Male.  25 

prostate  gland  as  examined  per  rectum.  Here  again  the 
hyperesthesia  is  extreme,  even  if  the  gland  is  not  markedly 
enlarged.  I  have  made  it  a  point  for  many  years  to  examine 
the  prostate  per  rectum  as  a  routine  in  every  genitourinary 
examination.  I  have  thus  made  many  examinations  in  acute 
and  chronic  urethitis,  in  acute  and  chronic  prostatitis,  in 
prostatic  abscess,  etc.,  but  in  none  of  these  conditions  is  the 
prostate  as  sensitive  as  in  cases  of  masturbation.  As  a 
general  thing  the  prostate  is  enlarged,  but  not  necessarily 
so,  and  it  is  alzvays  hyperesthetic. 

It  is  a  very  common  error  to  consider  that  m.asturbation 
is  always  accompanied  by  pollutions,  using  this  latter  term 
in  a  general  popular  sense,  without  distinction  whether 
spermatozoa  are  present  in  the  discharges  or  not.  I  cannot, 
however,  too  emphatically  state  that  masturbation  and  pol- 
lutions are  entirely  distinct  conditions  and  have  nothing  to 
do  with  each  other.  While  some  mastubators  also  suffer 
from  pollution,  still  in  a  very  large  number  of  cases  patients 
may  masturbate  without  ever  having  had  pollutions. 

It  is  also  a  mistake  not  to  think  of  masturbation  because 
the  patient  is  a  married  man.  In  a  small  percentage  of  cases 
married  men  masturbate  in  addition  to  performing  sexual 
coitus.  I  have  one  patient  who  is  so  passionate  that  during 
the  time  his  wife  is  indisposed  he  relieves  himself  by  mas- 
turbation. There  are  also  married  men  who  experience 
more  pleasure  from  masturbation  than  from  regular  sexual 
intercourse.  There  are  also  masturbators  who  get  married 
or  practise  illicit  connection,  upon  advice,  medical  or  other- 
wise, with  the  idea  of  curing  their  masturbation;  but  this 
does  not  succeed  and  they  continue  their  practice  in  addition. 


26  Disorders  of  the  Sexual  Function. 

This  is  a  very  important  point  and  will  be  again  referred  to 
under  treatment.  There  are  also  married  men  who,  while 
their  wives  are  temporarily  absent,  practise  masturbation. 

Again,  it  is  a  mistake  not  to  think  of  the  possibility  of 
a  chronic  gonorrhea  in  a  case  of  masturbation.  This  is  also 
important,  for,  if  we  do  not  recognize  it,  we  may,  by  treat- 
ing the  patient  for  masturbation,  light  up  his  old  gonorrheal 
infection  and  make  matters  worse.  There  are  masturbators 
who,  as  previously  stated,  think  of  curing  their  trouble  by 
coitus  and  thus  acquire  gonorrhea. 

But  all  these  special  symptoms,  which  we  have  tried  to 
analyze  in  detail,  give  but  a  poor  and  inadequate  picture  of 
the  confirmed  masturbator.  The  confirmed  masturbator  is 
apt  to  be  a  physical  coward,  a  man  who  will  stand  all  sort 
of  insult,  who  will  run  away  rather  than  fight  or  stick  up 
for  his  most  obvious  rights.  All  the  spirit  of  manhood 
seems  to  be  crushed  out  of  him.  He  is  very  often  praised 
for  his  gentleness,  for  his  saintlike  demeanor,  his  humility, 
etc.,  but  if  we  carefully  study  the  individual,  if  we  dive  into 
his  thoughts  and  make  a  psychical  study  of  them,  v/e  will 
find  that  these  traits  are  not  virtues.  We  will  find  that  he 
feels  his  wrongs  as  keenly  as  another,  that  he  makes  plans 
of  revenge  in  his  mind  which  he  would  fain  carry  out,  but 
which  he  has  not  the  energy  to  undertake  and  is  too  much 
of  a  coward  to  attempt.  He  is  good,  not  because  of  any 
virtue,  but  because  he  is  too  much  of  a  coward  to  be  bad. 

As  before  mentioned,  the  masturbator  is  essentially  a 
dreamer,  that  is,  he  is  very  much  occupied  with  his  own 
thoughts  and  is  very  shy  and  bashful  in  his  relationship 
with  the  outside  world.     He  is  especially  bashful  in  the 


Masturbation  in  the  Adult  Male.  2T 

presence  of  females.  He  feels  his  condition  keenly.  Some- 
times he  attempts  coitus  with  a  view  of  curing  his  condition, 
and  is  often  unsuccessful.  Frequently,  instead  of  mastur- 
bating with  his  hands  he  masturbates  with  his  brain, — that 
is,  he  calls  up  vivid  pictures  (psychic  masturbation)  and  so 
causes  erection  and  ejaculation.  These  cases  of  psychic 
masturbation  are  the  most  difficult  cases  to  cure,  and  the 
psychic  form  lasts  for  some  time  after  the  regular  form  has 
been  abandoned. 

And  so  he  continues  year  after  year;  the  number  of 
times  he  masturbates  varies  greatly  with  the  individual,  but 
it  is  astonishing  sometimes  to  hear  how  many  times  a  day 
and  for  how  long  a  period  he  can  keep  it  up.  It  is  this 
frequency  and  the  fact  that  he  needs  no  special  preparation 
or  place  of  convenience  that  constitutes  one  of  the  great  dif- 
ferences (but  not  the  only  one)  between  masturbation  and 
normal  coitus. 

It  is  really  remarkable  how  much  insult  the  sexual 
apparatus  will  stand  before  it  rebels.  If  coitus  were  prac- 
tised nearly  as  often  as  some  of  these  patients  masturbate, 
the  result  might  possibly  be  much  more  disastrous. 

But  after  a  while  he  comes  to  that  stage  where  he  mas- 
turbates, not  because  he  likes  it,  but  because  he  has  to.  He 
has  that  awful  irritation  in  his  deep  urethra,  and  he  simply 
must  masturbate.  The  periods  of  previous  excitement 
(pleasure)  become  less  and  less,  as  does  also  the  amount  of 
fluid  ejaculated.  Then  there  comes  a  time  when  he  cannot 
masturbate.  He  has  the  irritation,  he  has  the  impulse  to 
masturbate,  but,  no  matter  how  he  manipulates  his  penis  or 
how  he  excites  his  brain,  he  can  neither  obtain  an  erection 


28  Disorders  of  the  Sexual  Function. 

nor  an  ejaculation.  He  is  indeed  in  a  most  wretched 
condition. 

But  long  before  this  stage  is  reached  his  nervous  system 
has  been  severly  affected.  He  has  tremor  of  the  hands,  ex- 
cessive perspiration,  pains  all  over,  various  mental  symptoms 
{vide  supra), — in  fact,  the  amount  of  reflex  nervous  dis- 
turbance is  most  varied.  His  digestion  suffers ;  he  becomes 
morose  and  inattentive.  He  tries  coitus  and  finds  himself 
impotent,  but  may  however  contract  venereal  disease.  He 
has  tried  many  times  to  break  himself  of  the  habit,  but 
invariably  fails.  He  may  have  made  the  rounds  of  the 
various  advertising  quacks  and  found  no  relief.  He  then 
falls  into  despair  and  thinks  there  is  no  remedy  for  him  and 
that  he  is  doomed  to  perpetual  suffering.  It  is  useless  to 
talk  to  a  confirmed  masturbator  of  self-control,  because  he 
cannot  control  himself. 

I  have  attempted  to  describe  without  exaggeration  the 
course  of  masturbation  as  I  have  seen  it  in  dispensary  and 
private  practice.  It  is,  however,  not  every  case  that  goea 
on  to  this  very  last  condition.  The  disease  may  be  halted 
at  .any  stage  by  treatment.  I  have  attempted  to  give  a  gen- 
eral description,  but  no  one  description  will  fit  every  case. 
The  number  of  reflex  phenomena  are  as  numerous  as  the 
various  functions  of  the  nervous  system. 

Course  and  Prog-nosis. — As  a  general  thing,  between  the 
time  of  the  first  and  second  treatments,  the  patient  experi- 
ences once  the  desire  to  masturbate,  but  is  able  to  resist  the 
desire.  Already  after  the  second  treatment  the  patient  does 
not  even  experience  the  desire  to  masturbate.  The  prog- 
nosis is  therefore  excellent.     The  psychic  form  of  mastur- 


Masturbation  in  the  Adult  Male.  29 


bation  continues  somewhat  longer,  but  that  too  yields  after 
a  few  treatments.     It  is  wonderful  how  patients,  who  for 
years  have  had  that  terrible  pressing  need  to  masturbate, 
will,  in  only  the  small  space  of  one  or  two  weeks,  indeed,  al- 
ready after  the  first  treatment,  do  entirely  without  it.    But  of 
even  more  importance  than  the  genital  effect  of  the  treatment 
is  the  effect  on  the  character  of  the  patient  himself.     His 
whole  character  changes.   He  now  finds  delight  in  the  society 
of  women.  To  take  a  morose,  underfed,  ill-natured  man  and 
transform  him  in  a  little  while  into  a  jolly,  good-natured 
fellow,  full  of  the  spirit  of  life,  is  indeed  something  to  be 
proud  of.    But  this  is  not  the  exception ;  it  is  the  rule.    The 
only  reason  for  keeping  up  the  treatment  for  six  months  is 
not  so  much  for  fear  of  a  relapse,  but  that  it  takes  that  time 
fully  to  restore  the  prostatic  urethra  to  its  normal  condition. 
It  is  advisable  from  the  very  beginning  of  treatment  to 
explain  to  the  patients  the  dangers  of  illicit  sexual  inter- 
course,  and   this   warning  should   be   repeated   again  and 
again,  especially  as  the  patient  is  getting  well.     As  the  pa- 
tient is  getting  well,  his  new  enjoyment  of  life,  his  new 
interest  in  the  society  of  women,  his  greater  general  inter- 
course with  society,  theatre,  dances,  etc.,  often  beget  in  him 
a  normal  desire  for  sexual  intercourse,  which  can  easily  be 
restrained  by  a  few  words  of  advice.     It  has  already  hap- 
pened that  patients  have  been  cured  of  masturbation,  only 
to  come  back  to  the  dispensary  with  a  gonorrhea,  which 
some  seem  to  be  especially  proud  of  their  ability  to  obtain. 
Treatment. — Before  commencing  treatment  for  the  dis- 
ease proper,  it  is  necessary  to  determine,  or  have  determined 
by  competent  authority,  if  some  or  most  of  the  reflex  symp- 


30  Disorders  of  the  Sexual  Function. 

toms  are  due  entirely  to  masturbation  or  are  caused  by  some 
other,  possibly  more  important  organic  condition.  I  re- 
m.ember  a  good  many  years  ago  seeing  a  patient  who  had 
been  treated  by  one  of  our  advertising  "specialists"  for  "lost 
manhood"  and  whose  chief  symptoms  were  loss  of  weight 
and  energy  and  marked  perspiration,  but  who,  in  fact, 
although  a  masturbator,  was  well  advanced  in  pulmonary 
tuberculosis,  which  was  the  real  and  more  important  cause 
of  his  symptoms.  In  the  same  way  pains  over  the  eyes  and 
headache  may  h&  due  to  errors  of  refraction,  palpitation  of 
the  heart  to  organic  heart  disease  or  tobacco,  etc.,  or  the 
patient  may  be  a  psychopath  or  neurastheniac. 

It  is  also  advisable,  if  there  be  a  history  or  suspicion  of 
gonorrhea,  to  examine  the  entire  urinary  tract,  using  the 
anterior  and  posterior  endoscopes  if  thought  necessary  to 
determine  if  there  exists  any  pathological  condition  of  the 
canal.  Where  there  is  absolutely  no  suspicion  of  gonor- 
rhea, the  use  of  the  endoscope  as  well  as  all  unnecessary 
instrumentation  of  the  canal  had  better  be  omitted.  Need- 
less to  say,  the  urine  should  be  examined  as  a  routine  matter 
in  every  case. 

The  treatment  of  masturbation  proper  which  I  have 
employed  for  many  years  with  excellent  results  is  as 
follows : — 

The  patient  always  presents  himself  with  a  full  bladder ; 
this  is  important  for  two  reasons, — in  the  first  place  so  that 
the  patient  can  urinate  immediately  after  his  prostate  has 
been  massaged  and  so  expel  the  mucus  that  has  been  ex- 
pressed from  the  follicles,  and,  in  the  second  place,  it  is 
better  to  have  his  bladder  empty  after  the  injection  pres- 


Masturbation  in  the  Adult  Male.  31 

ently  to  be  described  has  been  given,  so  that  he  may  refrain 
from  urinating  for  some  time  after  the  injection.  Again, 
if  the  bladder  is  not  full  it  is  also  harder  to  reach  the  pros- 
tate and  more  difficult  to  massage  it,  and  in  addition  we 
also  get  an  entirely  wrong  idea  of  the  size  of  the  prostate 
if  palpated  per  rectum  with  the  bladder  emipty.  So  that  if 
the  patient  presents  himself  with  a  full  bladder,  it  is  easier 
to  palpate  his  prostate,  easier  to  massage  it,  and  easier  for 
him  to  empty  his  bladder  after  the  massage.  The  patient 
then  stands  with  his  buttocks  toward  the  physician,  and  the 
index  finger,  protected  by  a  finger  cot,  is  carefully  and  slowly 
introduced  into  the  anus  till  the  prostate  is  reached,  and 
the  prostate  is  then  gently  and  slowly  massaged.  The  pros- 
tate will  be  found  at  the!  first  examination  to  be  exquisitely 
tender  and  must  be  handled  very  gently,  remembering  that 
the  object  is  7iot  to  squeeze  out  every  drop  of  mucus  from 
the  prostatic  follicles,  as  we  attempt  to  do  in  certain  cases 
of  chronic  gonorrhea,  but  the  object  is  to  massage  it.  The 
first  seance  should  only  last  a  few  seconds,  and  on  subse- 
quent visits  the  prostate  will  generally  be  found  less  and  less 
sensitive,  and  the  length  of  time  of  massage,  as  also  the 
pressure  employed,  should  be  greater.  The  amount  of  pres- 
sure emplo3-ed,  as  well  as  the  length  of  time  of  massage, 
is  entirely  regulated  by  the  sensitiveness  of  the  organ.  As 
soon  as  the  prostate  has  been  massaged  the  patient  is  di- 
rected to  urinate,  but  he  will  have  some  difficulty  in  starting 
the  stream.  This  fact  is  noted  whenever  the  prostate  is 
massaged  for  any  condition  whatsoever, — that  the  patient 
with  a  full  bladder,  which  is  just  bursting  to  pass  water, 
will,  after  the  massage,  not  be  able  to  pass  it  and  have  little 


32  Disorders  of  the  Sexual  Function. 

desire  to  urinate.  It  may  be  necessary  for  the  physician  to 
leave  the  room  or  else  have  the  patient  go  to  a  regular 
toilet  before  he  is  able  to  start  the  stream. 

After  the  patient  has  emptied  the  bladder,  he  lies  down 
upon  the  table,  the  meatus  is  cleaned,  and  with  a  Bangs 
sound  syringe  a  i  :  3000  silver-nitrate  solution  is  instilled 
into  the  deep  urethra.  These  sound  syringes  come  in  sizes 
corresponding  to  the  regular  sounds.  There  are  some  who 
recommend,  instead,  the  passage  of  a  cold  ordinary  sound. 
I  have  tried  both  methods,  and  have  found  the  sound  syringe 
so  far  superior  to  the  cold  sound  that  I  have  given  up  the 
latter  since  many  years.  The  sound  syringe  must  be  lubri- 
cated with  some  substance  that  will  not  interfere  chemically 
or  mechanically  with  silver  nitrate ;  by  mechanically  I  mean 
it  must  not  coat  the  walls  of  the  urethra  with  an  impervious 
substance.  Vaselin  is  absolutely  useless  for  this  purpose. 
I  use  preparations  of  Irish  moss.  As  little  as  possible  of 
the  lubricant  should  be  put  on  the  instrument.  The  instru- 
ment should  be  introduced  gently  and  slowly  into  the  ure- 
thra till  its  tip  is  well  within  the  prostatic  urethra.  The 
urethra,  especially  the  prostatic  urethra,  will  be  found  very 
sensitive.  Those  who  have  not  learned  the  art  (and  it  is 
a  great  art)  of  introducing  an  instrument  slozvly  into  the 
urethra,  had  better  not  make  their  first  attempt  on  patients 
who  have  masturbated;  let  them  first  practise  on  some  old, 
insensitive  stricture  case. 

You  cannot  go  too  slowly.  When  the  instrument  is  in 
place,  a  few  drops  of  the  solution  are  deposited  in  the  deep 
urethra ;  there  is  absolutely  no  harm  if  some  of  the  solution 
should  get  into  the  bladder;  then  the  instrument  is  with- 


Masturbation  in  the  Adult  Male.  33 

drawn  a  trifle  and  a  few  more  drops  are  instilled,  and  so 
on.  Most  of  the  contents  of  the  syringe  are  instilled  into 
the  prostatic  urethra,  but  as  the  instrument  is  being  with- 
drawn, a  little  is  injected  all  along  the  anterior  urethra 
also.  This  is  all  that  is  done.  The  patient  is  told  to  retain 
his  urine  as  long  as  possible  after  the  treatment  and  to 
report  in  five  days.  He  is  cautioned  to  avoid  tea,  coffee, 
beer,  all  alcoholic  drinks,  also  eggs  and  oysters. 

At  first  a  very  small  size  sound  syringe  is  used,  as  well 
as  a  very  weak  solution  of  silver  nitrate.  As  the  case  pro- 
gresses, larger  size  sound  syringes  should  be  used  till  we 
get  it  as  large  as  the  meatus  will  stand.  The  strength  of 
the  silver  solution  is  also  increased  as  follows :  i  :  3000, 
I  :  2500,  I  :  2000,  I  :  1500,  i  :  1000,  and  i  :  500.  Our  chief 
guide  as  regards  the  size  of  the  instrument  used,  as  well  as 
the  strength  of  the  silver  solution,  is  the  sensitiveness  of 
the  urethra  as  judged  by  the  amount  of  burning  and  reac- 
tion produced  by  the  last  injection.  I  never  make  it  stronger 
than  1 :  500.  Those  who  have  little  experience  in  genito- 
urinary therapeutics  will  be  surprised  to  discover  what 
power  exists  in  ij^'eak  solutions  of  silver  nitrate. 

The  patient  is  seen  every  five  days  if  possible,  until  we 
have  reached  the  strongest  solution  of  the  silver  nitrate  and 
the  largest  size  sound  syringe,  then  once  a  week,  once  every 
two  weeks,  once  every  three  weeks,  once  a  month,  and  • 
finally  two  or  three  months  are  allowed  to  elapse  without 
treatment,  and  if  nothing  happens  he  is  pronounced  cured. 
The  entire  treatment,  including  the  long  intervals,  takes 
about  six  months,  but  the  number  of  visits  made  by  the 


34  Disorders  of  the  Seximl  Function. 


patient  is  very  small,  as  toward  the  end  the  intervals  of 
treatment  are  very  long  and  take  up  most  of  the  six 
months. 

There  are  some  physicians  with  whom  I  have  spoken 
who,  while  admitting  the  good  results  of  the  treatment,  aver 
that  the  treatment  is  merely  psychic.  Even  if  this  were  so, 
it  would  be  no  argument  against  the  treatment.  But  I  am 
certain  that  the  treatment  is  not  psychic  for  the  following 
reasons :  In  the  first  place,  the  hyperesthesia  of  the  urethra 
actually  exists,  as  can  easily  be  demonstrated  by  the  passage 
of  instruments.  And  in  the  second  place,  many  of  these 
patients  had  been  previously  subjected  to  treatment  which 
would  have  had  a  greater  hold  on  their  imagination  than 
the  treatment  above  outlined,  but  without  any  result  what- 
soever. Many,  for  instance,  have  had  electricity  applied 
to  various  portions  of  their  genital  tract,  including  the  deep 
urethra,  without  any  benefit.  Some  have  had  purely  psychic 
treatment,  even  including  hypnotism,  Christian  Science, 
and  the  like,  without  benefit.  I  must  repeat  that  I  am  refer- 
ring only  to  the  confirmed  adult  masturbator,  and  not  to 
the  child  that  has  just  been  taught;  to  manipulate  his  penis. 
As  stated  before,  the  latter  can,  before  any  hyperesthesia  of 
the  deep  urethra  has  been  produced,  be  simply  coaxed  out 
of  the  habit,  but  the  confirmed  masturbator  is  uninfluenced 
by  any  talking  or  psychic  treatment. 

Conclusions. — Masturbation  is  a  real  disease,  causing 
real  discomforts,  and  is  not  an  imaginary  condition. 

Do  not  blame  every  symptom  the  patient  complains  of 
on  his  masturbation,  as  they  may  be  due  to  pathological 
conditions  in  other  organs. 


Masturhatio  Internipta.  35 


Masturbation  and  pollutions  are  distinct  conditions, 
although  they  may  coexist. 

Masturbation  is  dependent  upon  a  pathological  condition 
of  the  prostatic  urethra  and  not  upon  imagination  on  the 
part  of  the  patient. 

Coitus  will  not  cure  masturbation  and  is  a  dangerous 
experiment. 

Masturbation  is  to  be  treated  by  removing  the  patho- 
logical condition  in  the  prostatic  urethra,  and  not  by  punish- 
ment or  talking  it  out  of  the  patient  or  appealing  to  his  self- 
control. 

Masturbation  is  a  curable  condition. 

IV.  MASTUEBATIO  INTERRUPTA. 

Rohleder^^*-  was  the  first,  I  believe,  to  call  attention 
to  this  form  of  masturbation.  It  only  occurs  in  the  male. 
This  is  a  condition  in  which  the  patient  masturbates,  but 
voluntarily  interrupts  the  procedure  just  before  ejacula'tion. 
In  ordinary  masturbation,  orgasm  and  ejaculation  is  the 
object  of  the  masturbator,  but  in  this  condition  there  is 
neither  orgasm  nor  ejaculation.  It  bears  the  same  resem- 
blance to  ordinary  masturbation,  that  coitus  interruptus 
bears  to  ordinary  coitus.  It  is,  however,  not  analogous  to 
coitus  interruptus,  for  in  the  latter  we  have  both  orgasm  and 
ejaculation,  while  in  this  condition  they  both  are  absent. 
Masturhatio  interrupta  may  be  compared  to  that  rare  form 
of  coitus  interruptus  in  which  the  penis  is  withdrawn  so 
early,  that  after  its  withdrawal  it  becomes  flaccid  and  no 
ejaculation  takes  place,  whereas  in  the  ordinary  cases  of 
withdrawal  ejaculation  does  take  place,  but  outside  of  the 


36  Disorders  of  the  Sexual  Function. 

vagina.  Masturbatio  interrupta  is  one  of  the  severest  forms 
of  sexual  neuroses,  and  has  for  its  consequences  the  evil 
results  of  masturbation  plus  those  of  coitus  interruptus. 
■  I  have  myself  seen  young  adults  who,  upon  being  caught 
in  the  act,  voluntarily  suspended  the  procedure  until  the  ob- 
server went  away,  and  then  continued.  Other  boys,  also, 
have  voluntarily  stopped  just  before  ejaculation,  so  as  not 
to  stain  the  bed-linen  and  so  avoid  detection.  Some  persons 
seem  to  have  the  notion  that  it  is  the  ejaculation  that  is  the 
weakening  thing  about  masturbation,  and  stop  just  before 
ejaculation. 

V.  MASTURBATIO  INCOMPLETA. 

This  is  a  rare  form  described  by  Rohleder^^'''  and  is 
characterized  by  a  precipitate  orgasm,  before  ejaculation. 
In  other  w^ords,  there  is  a  feeling  of  satisfaction  which  takes 
place  early  in  the  manipulation  and  which  ends  the  procedure 
and  no  ejaculation  takes  place  or  is  necessary,  as  the  pa- 
tient has  already  had  his  desired  orgasm.  As  soon  as  the 
patient  has  experienced  his  feeling  of  satisfaction  (orgasm) 
he  stops  just  as  if  an  ejaculation  had  taken  place.  This 
condition  is  the  result  of  many  years  of  masturbation,  which 
causes  an  irritable  weakness  in  the  end-organs  with  the  re- 
sult of  a  precipitate  orgasm. 

VI.  IMPOTENTIA  MASTURBATIONIS. 

By  this  term,  I  desire  to  describe  a  final  stage  or  rather 
severe  result  of  many  years  of  ordinary  masturbation.  In 
it,  although  the  patient  has  the  most  intense  desire  to  mas- 


Impotentia  Masturbafionis.  37 

turbate,  yet  in  spite  of  the  most  prolonged  manipulation  of 
his  genitalia  or  of  the  most  intense  attemipts  at  psychic  mas- 
turbation, no  ejaculation  can  be  brought  forth.  It  is  but  an 
extreme  case  of  ordinary  masturbation. 

The  pathology  and  treatment  of  all  these  lasi:  three  forms 
of  masturbation  are  the  same  as  that  of  the  ordinary  variety 
in  the  adult  male. 


CHAPTER  III. 
VII.  MASTURBATION  IN  THE  ADULT  FEMALE. 

Genera  etiology.  Etiology  in  unmarried  adults.  Etiology  in  mar- 
ried adults.  Impotence  in  the  male  and  coitus  interruptus  as  causes. 
Methods  employed  in  masturbation.  Psychic  masturbation.  Pathol- 
ogy. Physiology  of  normal  coitus  in  the  female.  Local  symptoms. 
General  symptoms.  Course  and  prognosis.  Reflex  symptoms.  Diag- 
nosis. Local  treatment.  General  treatment.  Marriage  not  a  cure  for 
masturbation.     Importance  of  instructing  the  husband. 

Etiology. — Any  of  the  conditions  mentioned  in  the  etiol- 
ogy of  masturbation  in  the  young  girl  may  also  cause  the 
trouble  in  the  adult.  In  some  cases  the  condition  simply 
goes  on  from  childhood  and  continues  uninterruptedly  into 
adult  life,  and  it  has  even  been  known  to  persist  into  the 
climacterium. 

Besides  the  above-mentioned  factors,  there  are  certain 
special  conditions  which  are  the  cause  of  masturbation  in 
the  adult  female.  These  etiological  factors  may  be  divided 
as  follows:  (a)  in  unmarried  adults ;  (b)  in  married  adults. 

(a)  Etiology  in  Unmarried  Adult  Females. — Tempera- 
ment and  mode  of  life  are  very  decisive  elements  in  determ- 
ining a  predisposition  to  masturbation.  Girls  of  a  passionate 
temperament,  whether  this  temperament  has  been  inherited 
or  has  been  artificially  produced  by  early  mixture  with  the 
young  of  the  opposite  sex,  are  especially  prone  to  fall  into 
the  habit.  The  reading  of  erotic  literature,  instruction  and 
so-called  enlightenment  on  sexual  matters  from  older 
females,  suggestive  plays  and  moving-picture  shows  are  all 
conducive  to  the  formation  of  the  habit.  According  to 
(38) 


Masturbation  in  the  Adult  Female.  39 

Howard^^  "long  marriage  engagements,  during  which  the 
parties  have  seen  much  of  each  other  alone,  and  finally  break 
their  relations,  have  been  the  cause  in  some  of  my  cases. 
Such  women  have  been  under  constant  sexual  excitement; 
when  the  disappointment  comes  the  result  is  a  great  psychic 
shock,  restraint  no  longer  holds  or  controls  them,  and  the 
culmination  is  a  catharsis  of  passion  which  is  certain  to  be 
fed  in  an  unnatural  way.  This  is  what  Hall  calls  short- 
circuited  sexual  indulgence,  because  all  the  routes  of  ap- 
proach— anticipation,  embraces,  and  other  natural  stimuli 
to  the  secondary  sexual  organs — have  been  jumped." 

It  is  a  sad  commentary  upon  the  censorship  or  decency 
of  our  journals  and  newspapers  that  certain  apparently 
innocent  advertisements,  skillfully  worded  to  avoid  the  law, 
yet  suggestive  enough,  should  be  allowed  to  come  to  the 
attention  of  respectable  girls  and  perhaps,  through  curiosity, 
prompted  by  a  teasing  sexual  temperament,  arouse  in  them 
the  habit  of  masturbation.  "Rubber  Goods,"  "Hygienic 
Pads,"  "Guides  to  Happiness,"  "How  to  be  Happy  though 
Unmarried,"  etc.,  each  accompanied  by  sensual  descriptive 
literature,  are  but  a  few  examples  of  the  various  methods 
employed  to  attract  the  attention  of  the  innocent.  There 
are  stores  that  manufacture  articles  to  be  used  for  mastur- 
bation by  the  female,  and  use  the  above  methods  to  bring 
their  goods  to  the  attention  of  the  sex. 

(&)  Etiology  in  Married  Adult  Females. — The  same 
etiological  factors  which  determine  masturbation  in  the 
unmarried  may  at  times  cause  it  in  the  married  female.  As 
has  been  already  mentioned,  the  habit  which  has  been  started 
in  girlhood,  may  continue  uninterruptedly  during  married 


40  Disorders  of  the  Sexual  Function. 

life,  in  spite  of  or,  rather,  in  addition  to  normal  sexual  inter- 
course, and  may  remain  uninfluenced  by  either  coitus,  preg- 
nancy, lactation,  or  even  the  menopause.  As  a  matter  of 
fact,  the  chronic  female  masturbator,  if  she  marries,  experi- 
ences little  if  any  pleasure  from  coitus,  and  certainly  more 
pleasure  from  masturbation  than  from  coitus.  This  is  due  to 
the  fact  that,  on  account  of  the  oft-repeated  manipulation  of 
the  clitoris  and  urethra,  she  has  rendered  these  parts  so  ex- 
quisitely hypersensitive  that  the  sensation  produced  by  the 
ordinary  act  of  coitus  (the  friction  of  the  penis  against  the 
vaginal  walls,  etc.)  cannot  compare  with  that  oft  the  mas- 
turbatory  manipulations  of  the  sensitive  external  parts.  In 
other  words,  the  impulses  of  normal  coitus  are  insufficient 
to  arouse  the  sexual  centers. 

But  besides  the  above  etiological  factors,  which  are  com- 
mon to  both  the  unmarried  and  the  married  female,  we  have 
two  very  important  factors  which  come  into  play  only  in  the 
married.  These  are  rapid  or  premature  ejaculation  on  the 
part  of  the  male,  and  also  coitus  interruptus.  Both  of  these 
factors  act  in  a  similar  manner,  and  their  action  will  be  dis- 
cussed under  the  pathology. 

Methods  Employed  in  Masturbation. — B  esides  the 
ordinary  methods  of  manipulation  of  the  genitals  with  the 
hands,  and  thigh  friction,  the  methods  employed  for  the  pur- 
poses of  masturbation  are  too  numerous  to  be  mentioned. 
It  should  be  remembered  that  the  sexual  sense  is  more 
developed  in  the  female  urethra  than  in  any  other  portion 
of  the  external  genitals,  not  excluding  the  clitoris.  Hence 
it  is  that  this  portion  of  the  anatomy  is  so  frequently  irri- 
tated by  all  sorts  of  implements,  and  that  so  often  foreign 


Masturbation  in  the  Adult  Female.  41 

bodies,  such  as  hair-pins,  knitting-needles,  etc.,  find  their 
way  through  carelessness  into  the  bladder.  Pencils  are  also 
inserted  into  the  urethra.  Among  the  more  common  methods 
may  be  mentioned  pillow  masturbation,  the  insertion  of  a 
key  or  other  instrument  (especially  in  the  married)  into 
the  vagina.  Artificial  penes  have  been  invented  and  are 
sold  for  this  purpose  by  certain  firms.  Tallow  candles  are 
also  very  frequently  used.  Bananas,  cucumbers,  and  simi- 
lar fruit  have  been  used  as  well. 

Talmey^^*  states  as  follows:  "The  Japanese  women, 
according  to  Ellis,  use  two  hollow  balls  about  the  size  of  a 
pigeon's  egg;  one  is  empty,  the  other  contains  a  small,  but 
heavy  metal  ball,  or  some  quick-silver,  so  that  if  the  balls 
are  held  in  hand  side  by  side  there  is  a  continuous  move- 
ment. The  empty  ball  is  first  inducted  into  the  vagina,  in 
contact  with  the  uterus,  then  the  other.  The  slightest  move- 
ment of  the  pelvis  or  thighs  causes  the  metal  or  mercury- 
ball  to  roll,  and  the  resulting  vibration  produces  a  prolonged 
voluptuous  titillation,  a  gentle  shock,  as  from  a  weak  electric 
inductive  apparatus.  The  balls  are  held  in  the  vagina  by 
a  tampon.  The  women  then  delight  to  swing  themselves 
in  hammocks  or  rocking-chairs,  the  delicate  vibrations  of 
the  balls  slowly  producing  the  highest  degree  of  sexual 
excitement." 

Coming  now  to  the  other  method  of  producing  Onanism 
without  the  use  of  the  hands  or  any  implements  whatso- 
ever, we  have  the  psychic  Onanism.  In  this  method  the 
orgasm  is  produced  solely  by  central  stimulatory  represen- 
tations. Lascivious  trains  of  thought,  sometimes,  though 
by  no  means  always,  the  results  of  previous  experience,  are 


42  Disorders  of  the  Sexual  Function. 

recalled.  There  is  almost  as  much  variety  here  as  in  the 
manual  or  instrumental  method.  Schrenk-Notzing^^"^  re- 
cords the  case  of  a  female  Onanist  who  induced  orgasm 
simply  by  hearing  music  or  while  regarding  paintings  that 
displayed  nothing  of  a  lascivious  character.  As  in  the  male, 
these  are  the  worst  forms  of  the  malady  and  the  strain 
upon  the  nervous  system  and  upon  the  imagination  is 
exceedingly  harmful.  It  is  just  this  form  which  is  more 
deleterious  in  its  results  than  normal  coitus  could  be,  even 
if  coitus  could  be  indulged  in  as  often  as  masturbation. 

Pathology. — In  those  cases  due  to  a  local  irritation, 
there  is  at  first,  as  in  the  male,  a  local  hyperesthesia  of  the 
parts  from  which  impulses  are  sent  to  the  sexual  centers  in 
the  brain.  It  is  obvious  that  as  long  as  the  local  irritation  is 
not  removed  the  impulses  are  constantly  being  sent  to  the 
centers.  If  the  habit  has  been  persisted  in  for  a  long  time, 
from  the  purely  mechanical  effects  of  the  continued  pulling 
and  manipulation  of  the  external  genitals,  these  parts  re- 
main hypersensitive,  even  though  the  original  irritation  has 
been  removed.  These  parts  then  become  more  sensitive 
than  the  mucous  membrane  of  the  vagina,  and  so,  if  such 
patients  marry,  the  stimulation  of  the  latter  parts  by  ordi- 
nary coitus  is  not  sufficient  to  excite  the  sexual  centers  suf- 
ficiently, and  orgasm  does  not  occur  except  with  the  aid  of 
self-friction.  The  same  condition  of  affairs  may  be  said  to 
exist  in  psychic  masturbation.  Here,  on  account  of  the 
very  frequent  repetition  of  the  act,  the  sexual  centers  be- 
come exhausted  or  dulled,  and  more  and  more  psychic 
stimulation  is  necessary  to  arouse  them.  As  a  result  the 
amount  of  psychic  stimulation  necessary  to  arouse  the  sexual 


Masturbation  in  the  Adult  Female.  43 

centers  is  greater  than  stimulation  of  these  centers  by  nor- 
mal coitus,  and  so,  again,  we  see  why  normal  coitus  in 
these  chronic  cases  will  not  lead  to  orgasm,  or  produce  the 
desired  effect,  and  why  the  patients  prefer  masturbation  to 
coitus. 

When  we  come  to  cases  in  which  masturbation  was  first 
started  during  married  life,  after  a  period  of  normal  coitus, 
due  to  withdrawal  or  impotence  on  the  part  of  the  husband, 
we  have  an  entirely  different  pathology.  To  thoroughly 
understand  it,  it  will  be  necessary  to  describe  briefly  the 
physiology  of  normal  coitus  in  the  female,  for  here,  as 
everywhere  else,  pathology  is  but  perverted  physiology. 

In  the  woman,  with  the  commencement  of  coitus,  there 
is  a  general  hyperemia  of  all  the  pelvic  organs.  In  a  nor- 
mal coitus  with  fully  developed  orgasm,  and  the  expulsion 
of  the  secretions  from  the  genital  glands,  a  deplethori- 
zation  occurs,  and  the  pelvic  organs  are  left  in  their  natural 
condition. 

If,  however,  the  act  is  interrupted  by  withdrawal  or  by 
rapid  or  premature  ejaculation  on  the  part  of  the  husband, 
the  orgasm  in  the  female  either  does  not  occur  at  all  or 
takes  place  incompletely  and  the  sexual  glands  do  not  ade- 
quately empty  themselves;  in  other  words,  the  female  does 
not  really  "come,"  the  pelvic  organs  remain  hyperemic,  and 
after  this  state  of  affairs  has  continued  for  a  time  a  con- 
dition of  chronic  congestion  of  the  pelvic  organs  takes 
place,  with  all  its  deleterious  results. 

I  would  remark,  and  shall  frequently  have  occasion  to 
emphasize  the  fact,  that  in  even  so-called  normal  coitus  the 
woman  does  not  receive  the  consideration  she  deserves  in 


4-4  Disorders  of  the  Sexual  Function. 

the  vast  majority  of  cases.  From  a  very  large  experience 
and  study  of  these  cases  I  have  come  to  the  conclusion  that 
very  few  men  know  how  to  perform  the  sexual  act  cor- 
rectly. As  a  general  thing,  even  in  so-called  normal  coitus, 
the  man  only  considers  himself,  and  not  the  woman  at  all. 
We  find  that  when  the  man  has  an  erection  he  immediately 
starts  coitus,  whether  the  woman  has  desire  or  not,  and  in 
many  cases  when  she  is  but  half -awakened.  As  soon  as  he 
has  completed  his  part  of  the  act,  he  stops  and  removes 
his  penis.  As  a  result,  at  the  commencement  of  coitus  the 
woman  is  not  fully  excited  and  only  becomes  half-way  ex- 
cited during  the  act,  but  remains  excited,  and  has  not  nearly 
completed  her  part  of  the  act  when  her  husband  ceases  to 
perform.  In  questioning  many  women,  I  have  been  told 
by  them  that  they  experience  little  pleasure  during  the  sex- 
ual act,  but  become  excited  afterward.  As  a  result  of  this 
lack  of  deplethorization,  and  the  resulting  congestion  of 
the  genital  organs  (made  much  worse  by  withdrawal)  and 
the  state  of  sexual  excitement  after  coitus,  it  is  easy  to 
understand  how  such  women  easily  fall  a  prey  to  mastur- 
bation to  complete  the  orgasm. 

The  pathology  of  psychic  masturbation  is  the  same  as 
in  the  adult  male  and  has  been  described  on  page  19. 

Symptoms  of  Masturbation  in  the  Female. — The  symp- 
toms may  be  divided  into  local  and  general. 

Local  Symptoms. — The  local  symptoms  are  due  to  the 
local  irritation  set  up  by  the  manipulation  of  the  parts.  In 
many  cases  I  have  made  the  diagnosis  of  masturbation 
from  an  examination  of  the  external  genitals  and  have 
thus  compelled  a  confession  on  the  part  of  the  patient. 


Masturbation  in  the  Adult  Female.  45 

One  of  the  most  characteristic  signs,  in  a  case  where  mas- 
turbation has  been  practised  for  a  long  time,  is  an  hyper- 
trophy of  the  labia  minora.  On  account  of  the  pulling  to 
which  these  parts  have  been  subjected,  they  are  enor- 
mously increased  in  size,  and  Howe^^  reports  to  have  found 
them  two  and  one-half  inches  in  breadth  and  to  look  very 
much  like  the  ears  of  a  spaniel.  They  are  dark-colored, 
often  pigmented  and  parchment-like,  while  their  base  may 
be  red  and  swollen.  There  is  often  intense  redness  and 
spots  of  excoriation  near  the  vaginal  entrance  and  some- 
times we  find  a  mucopurulent  secretion  bathing  the  external 
genitals.  If  the  urethra  has  been  used  for  purposes  of 
masturbation  we  wnll  be  sure  to  find  signs  of  local  irrita- 
tion within  the  meatus.  As  a  general  thing,  in  the  unmar- 
ried, the  hymen  will  be  found  intact.  According  to  Veit, 
as  quoted  by  Kisch,^^  we  have  a  chronic  vulvitis  which  is 
met  with,  though  rarely,  as  a  sequence  of  masturbation. 
He  gives  the  following  description  of  this  masturbatory 
vulvitis : — 

"As  characteristic  signs  of  this  we  may  observe  an 
elongation  of  the  nymphse,  the  clitoris,  or  the  prceputium 
clitoridis,  and  at  the  same  time,  on  the  inner  surface  of  the 
greatly  stretched  labise,  we  may  notice  a  great  increase  in 
the  sebaceous  glands,  so  that  the  yellowish  spots  formed 
by  these  structures  may  be  seen  beneath  the  mucous  mem- 
brane with  the  unassisted  eye.  The  mucous  surface,  indeed, 
may  be  slightly  uneven  in  consequence  of  their  enlargement, 
so  that  they  resemble  small  retention  cysts.  The  mucous 
membrane  of  the  vulva  between  the  margin  of  the  hymen 
and  the  nymphae  is,  moreover,  often  beset  with  small  pointed 


46  Disorders  of  the  Sexual  Function. 

excrescences,  the  soft  furrow  between  the  cHtoris  and  the 
external  orifice  of  the  urethra  being  very  commonly  marked 
by  swelling  of  the  mucous  membrane  and  the  presence  of 
these  little  outgrowths;  but  sometimes  also  the  parts  lying 
to  either  side  of  the  urethral  orifice  may  exhibit  similar 
changes.  These  small  structures  differ  entirely  from 
pointed  condylomata — they  do  not  branch,  they  occur  only 
upon  the  vulval  surface  proper,  not  upon  the  parts  exhibit- 
ing the  characters  of  true  skin,  and  they  are  non-infecting. 
More  particularly,  it  must  be  remembered,  we  find  these 
changes  principally  in  virgins  in  whom  on  account  of  ob- 
scure symptoms  an  examination  of  the  genital  organs  has 
been  undertaken,  and  who  suffer  in  addition  from  nervous 
and  hysterical  manifestations."  The  hymen,  when  intact, 
as  it  usually  is  in  these  cases,  furnishes  objective  evidence 
that  sexual  intercourse  is  not  the  cause  of  the  patient's 
trouble,  and  indeed  a  distinctly  ascertainable  cause  is  hard 
to  find.  The  patient  usually  exhibits  abnormal  sensitive- 
ness and  excessive  prudery,  Veit  is  of  opinion  that  the 
association  of  all  these  symptoms  justifies  the  diagnosis  of 
masturbation  as  the  exciting  cause  of  the  chronic  vulvitis; 
in  such  cases  we  may  at  one  time  find  the  mucous  mem- 
brane pale,  but  at  a  later  examination  fiery  red,  and  we 
often  see  a  clear,  transparent  secretion  exuding  from  thq 
ducts  of  Bartholin's  glands." 

General  Symptoms. — The  general  symptoms  vary  greatly 
in  their  intensity  in  different  individuals.  They  are,  as  a 
general  thing,  more  marked  in  those  of  a  neurasthenic  or 
hysterical  tendency.  It  must  be  distinctly  emphasized,  how- 
ever, that  there  are  cases,  and  these  by  no  means  rare,  in 


Masturbation  in  the  Adult  Female.  47 

which  the  habit  has  been  continued  for  many  years,  and  in 
which  the  patient  experiences  no  ill  effects  whatsoever. 
Upon  this  point  Herman'*^  remarks :  "My  impression  as  to 
the  effect  of  masturbation  in  the  adult  is  that  in  the  frankly 
sensual  pagan  woman,  who  gratifies  her  impulse  and  thinks 
no  more  about  it,  masturbation  does  little  harm.  The  pa- 
tients who  suffer  from  it  are  the  very  sensitive  religious 
people  who  think  it  a  great  sin,  and  are  continually  strug- 
gling against  it.  It  is  the  struggle,  as  much,  or  more  than 
the  masturbation,  that  weakens  the  nervous  system,  and 
keeps  attention  fixed  on  the  genital  organs." 

As  a  general  rule  it  may  bd  stated  that  the  earlier  the 
habit  has  been  started,  after  adolescence  has  been  estab- 
lished, the  worse  is  the  effect  and  the  more  severe  are  the 
general  symptoms.  The  cases  which  have  begun  the  habit 
only  after  marriage,  and  have  gone  into  the  habit  as  a 
result  of  rapid  ejaculation  or  other  forms  of  impotence  or 
withdrawal  on  the  part  of  the  husband,  will  very  often 
result  in  no  ill  effect  whatsoever,  especially  where  the 
women  have  for  several  years  experienced  normal  coitus. 
Indeed,  so  mild  are  the  symptoms,  if  any,  in  these  cases, 
that  so  great  an  authority  as  Rohleder^^'''  actually  advises 
titillation  of  the  clitoris  by  the  husband  until  orgasm  is  pro- 
duced after  coitus  interruptus  in  those  cases  where  both 
parties  do  not  want  to  have  any  more  children  and  by 
mutual  consent  practise  withdrawal.  The  reason  for  this  is 
easy  to  find.  In  the  unmarried,  the  female  has  to  draw 
very  largely  upon  her  imagination  to  produce  an  orgasm 
in  psychic  masturbation,  while  in  one  who  has  already 
experienced  coitus,  especially  if  practised  during  coitus  or 


48  Disorders  of  the  Sexual  Function. 

after  coitus  interruptus,  the  strain  on  the  imagination  is 
practically  nil.  Those  practising  purely  psychic  mas- 
turbation, especially  if  unmarried,  have  the  worst  general 
symptoms. 

Taking  it  all  in  all,  the  symptoms  are  similar  to  those 
just  described  in  the  adult  male,  though  not  nearly  as 
severe.  In  some  cases,  however,  they  are  very  intense. 
The  young  unmarried  female  adult  is  shy  and  retiring,  and 
does  not  seek  or  enjoy  the  company  of  the  opposite  sex. 
She  is  easily  embarrassed,  and  morbid  blushing  is  often  a 
very  prominent  symptom.  Her  sexual  character  is  often 
entirely  altered.  If  she  marries,  after  she  has  practised 
masturbation  for  a  long  time  previously,  she  gets  no  enjoy- 
ment out  of  the  sexual  act.  The  cause  for  this  has  already 
been  explained  on  page  42.  Very  often  normal  coitus  is 
not  sufficient  to  bring  her  to  the  orgasm,  and  she  has  to 
resort  to  titillation  of  the  clitoris  during  or  just  before  or 
after  the  act.  The  reflex  symptoms  vary  greatly  and  are 
too  numerous  to  be  mentioned,  but  prominence  must  be 
given  to  vague  cardiac  symptoms,  such  as  palpitation,  and 
also  in  some  cases  a  feeling  by  the  patient  of  blood  rushing 
powerfully  through  the  carotids  and  a  feeling  of  throbbing 
in  these  parts.  Very  often  these  patients  seek  their  physi- 
cian for  these  cardiac  symptoms,  and  if  the  latter  is  not  on 
his  guard  he  may  be  perplexed  or  even  make  a  wrong  diag- 
nosis of  functional  cardiac  disease.  This  actually  happened 
with  a  patient  of  mine,  who  consulted  a  very  prominent 
cardiac  specialist,  and,  although  the  latter  found  no  organic 
heart  trouble  present,  entirely  failed  to  realize  the  real  origin 
of  the  trouble,  and  actually  had  the  wedding  of  the  patient 


Masturbation  in  the  Adult  Female.  49 

postponed  for  an  entire  year, ,  sending  the  patient  to  the 
country  to  rest  up.  In  the  above  case,  the  patient  entirely 
recovered  without  any  treatment  whatever,  as  soon  as  she 
was  married.  She  remained  well  for  over  four  years,  dur- 
ing which  time  she  gave  birth  to  two  children.  Then  all 
her  symptoms  returned,  and  upon  close  inquiry  I  was 
informed  that  for  several  months  past  she  did  not  allow 
her  husband  to  have  normal  coitus  with  her  on  account  of 
fear  of  pregnancy,  but  only  permitted  him  to  insert  the 
penis  against  her  thighs  without  even  touching  the  external 
genitals. 

This  was  virtually  similar  to  masturbation.  Upon 
getting  her  to  stop  this  method  of  abnormal  coitus,  all  her 
symptoms  again  vanished.  Should  such  a  patient  actually 
have  in  addition  a  real  organic  heart  condition,  accompanied 
by  some  valvular  murmur,  one  can  easily  see  how  much 
more  complicated  the  position  becomes,  and  how  the  physi- 
cian must  be  on  his  guard  to  properly  interpret  the 
symptoms. 

Among  the  other  more  common  general  symptoms  may 
be  mentioned  backache  and  headache.  These  symptoms, 
however,  are  so  very  frequently  met  with  in  women,  that  we 
must  be  careful,  first  of  all  to  rule  out  other  possible  patho- 
logical factors.  It  would  be  very  sad  to  let  a  woman  go 
on  for  years  with  a  renal  calculus,  a  retroflexion  or  other 
organic  trouble  and  blame  the  symptoms  upon  masturbation. 
Similarly,  as  in  the  male,  headache  is  very  often  due  to 
eye-strain  and  dizziness,  to  a  catarrhal  or  stenosed  con- 
dition of  the  eustachian  tube,  causing  a  retraction  of  the 
tympanum.    All  these  conditions  must  be  thought  of. 


50  Disorders  of  the  Sexual  Function. 

Diagnosis. — Just  as  in  other  medical  conditions,  the 
diagnosis  may  be  very  easy  if  we  have  the  possibility  of 
the  condition  in  mind,  and  exceedingly  difficult  if  we 
never  dream  of  such  a  condition.  We  must  not  be  led 
astray  by  social  or  other  conditions.  Just  because  the 
female  is  a  college  girl,  is  refined  and  educated,  and  an 
ardent  churchgoer,  is  absolutely  no  reason  for  not  suspect- 
ing masturbation  as  a  possible  cause  of  obscure  symptoms. 
He  who  considers  every  case  of  nervousness  in  a  young 
girl  as  due  to  the  development  of  the  menstrual  function, 
overwork  at  school  or  college,  etc.,  will  never  make  a  diag- 
nosis of  masturbation.  Again,  one  must  not  forget  to  think 
of  it  as  a  cause  because  the  woman  is  married  and  has 
children,  for,  as  above  stated,  while  it  is  rather  rare  for 
married  men  to  masturbate,  it  is  not  at  all  uncommon  in 
married  women.  It  often  requires  considerable  tact  to  get 
the  girl  or  woman  to  confess,  but  in  the  majority  of  cases 
we  can  get  the  history  if  we  only  think  of  the  possibility 
of  the  habit. 

An  excellent  method,  which  I  have  very  often  found  to 
work  like  a  charm,  is  to  catch  the  patient  off  her  guard. 
In  married  women  an  examination  of  the  genitals  is  easy 
to  obtain,  and  we  can  often  make  our  diagnosis  from  that 
alone.  If  we  are  reasonably  sure  of  our  diagnosis,  we  say 
to  the  patient,  in  a  matter  of  fact  way,  "Of  course  you 
fool  with  yourself  occasionally."  No  answer  to  this  ques- 
tion, or  a  delayed  negative  answer,  is  as  good  as  a  confes- 
sion. In  single  girls  a  genital  examination  is  not  advisable 
as  a  rule,  but  the  intelligent  mother  can  be  instructed  what 
to  look  for  and  to  watch  the  girl.    A  private  talk  with  the 


Masturbation  in  the  Adult  Female.  51 

young  lady,  with  the  above  question,  especially  after  a 
careful  general  examination  of  the  heart  and  other  organs, 
will  also  generally  bring  about  a  confession.  Many  people, 
especially  the  young,  have  a  rather  exaggerated  idea  of  the 
knowledge  and  possibilities  of  diagnosis  by  a  physician,  and 
so  it  is  not  unusual  for  a  young  girl  to  think  that  a  physi- 
cian by  listening  to  her  heart  can  find  out  that  she  prac- 
tises masturbation.  The  disciples  of  Freud  have  little 
difficulty  in  getting  at  the  sexual  history  of  their  patients. 
Whenever  a  young  girl  likes  to  sit  by  herself,  and  does  not 
care  to  mix  either  in  play  or  study  with  her  companions, 
and  especially  if  she  does  not  care  for  the  opposite  sex,  or 
if  she  is  a  dreamer,  we  should  suspect  masturbation.  On 
the  other  hand,  as  already  stated,  even  if  we  have  correctly 
made  the  diagnosis  of  masturbation,  we  should  not  allow 
ourselves  to  fall  into  the  opposite  error,  of  blaming  all  her 
symptoms  upon  this  habit,  but  should  also  consider  the  pos- 
sibility of  errors  in  refraction,  digestion,  assimilation,  gyne- 
cological, neurological,  orthopedic  and  other  conditions 
being  present  simultaneously.  In  practically  every  case 
where  a  foreign  body  is  found  in  the  female  urethra  or 
bladder  it  has  been  introduced  from  without  and  mastur- 
bation is  the  direct  cause. 

Treatment  of  Masturbation  in  the  Female. — Local  Treat- 
ment.— All  local  irritations  of  whatsoever  nature  must  be 
removed.  Eczematous  and  intertriginous  conditions  about 
the  genitals  must  be  relieved.  It  makes  no^  difference 
whether  the  local  condition  is  the  cause  or  the  consequence 
of  the  masturbation.  Even  if  not  the  cause,  it  serves  to 
keep  up  the  habit,  to  attract  the  attention  of  the  patient  to 


52  Disorders  of  the  Sexual  Function. 

her  genitals,  and  retards  a  cure.  Gymnastic  exercises  which 
might  bring  into  play  thigh  friction,  also  sliding  down  the 
bannisters  and  similar  amusements  should  be  interdicted. 
Operations  on  the  genitals  do  no  good  unless  some  distinct 
condition,  aside  from  the  habit,  presents  itself. 

General  Treatment. — "Confession,"  says  Howard 
Kelly, •'^  "however  fragmentary,  is  a  long  first  step  toward 
recovery."  For  this  reason  I  have  laid  such  great  stress 
upon  being  upon  the  alert  and  upon  the  lookout  for  the  habit 
and  so  getting  a  confession  from  the  patient,  by  taking  her 
off  her  guard.  Both  as  a  preventive  and  as  a  curative  meas- 
ure, we  must  positively  interdict  coffee,  tea,  and  alcoholics. 
In  bad  cases  we  may  administer  bromides,  but  for  a  short 
period  only.  We  must  not  rely  upon  them  as  a  curative 
measure. 

The  most  important  agency  in  curing  the  habit  is,  in 
the  first  place,  to  remove  all  psychic  conditions  which  stimu- 
late the  sexual  imagination.  Under  this  heading  come 
erotic  literature,  impure  plays,  moving  pictures,  etc.  In 
the  second  place,  we  must  substitute  some  good  habit  for 
the  bad  one.  Howard  Kelly^^  rightly  says  that  our  motto 
should  be :  "To  replace  is  to  conquer."  Any  outdoor  hobby 
such  as  swimming,  golfing,  and  tennis  is  good.  In  trying  to 
break  the  habit,  we  must  use  very  much  tact.  We  must  not 
talk  in  vague  hints,  but  place  the  issue  fairly  and  squarely 
before  the  patient.  We  must  help  her  to  help  herself.  We 
must  try  to  develop  her  will-power  and  self-control.  'Noth- 
ing is  so  good  for  these  patients  as  hard  work,  no  matter 
of  what  kind,  as  it  keeps  them  occupied.  Any  inclination 
to  be  by  themselves  should  be  discouraged. 


Masturbation  in  the  Adult  Female.  53 

Long  marriage  engagements  should  be  greatly  discour- 
aged, for  they  keep  up  in  both  parties  a  state  of  sexual 
erethism  which  easily  leads  into  masturbation. 

Yet  one  word  more  in  regards  to  masturbation  in  adults. 
Never  advise  marriage  as  a  cure.  The  marriage  state  is 
too  sacred  and  too  serious  a  condition  to  be  used  either  as 
a  preventive  or  as  a  cure  for  masturbation.  Such  vague 
hints  as  "Nothing  will  cure  your  nervousness  as  marriage" 
are  both  unscientific  and  undignified  from  the  conscientious 
physician.  Besides,  such  hints  may  not  be  without  danger 
to  the  weakling.  I  have  heard  of  at  least  one  female  who 
took  to  illegal  coitus  because  her  physician  said  that  mar- 
riage was  necessary  to  her  health. 

In  married  women  who  have  taken  up  the  habit  as  a 
consequence  of  unsatisfied  desire  due  to  the  huband's  im- 
potence, withdrawal  or  any  of  the  other  conditions  above 
mentioned,  the  cure  of  the  husband  and  his  proper  instruc- 
tion in  sexual  matters  is  essential.  Although  Sturgis^^^ 
many  years  ago  called  attention  to  these  conditions,  they 
have  not  received  the  consideration  they  deserve.  It  may 
seem  ridiculous  to  some  physicians  to  be  told  that  normal 
men  ought  to  be  instructed  into  the  proper  method  of  hav- 
ing coitus,  yet  to  the  sexologist  nothing  is  more  common 
than  the  dense  ignorance  on  this  very  matter  found  among 
so-called  "normal  men." 

Although  this  subject  will  be  more  fully  discussed,  in 
describing  the  evil  consequences  of  withdrawal,  a  few  words 
may  not  be  amiss  in  this  connection. 

The  husband  is  to  be  made  aware  of  the  fact  that  the  wife 
has  a  well-marked  sexual  sense  and  desire,  and  her  desire 


54  Disorders  of  the  Sexual  Function. 

and  passion  should  be  taken  into  consideration  in  his  mari- 
tal duties.  He  should  be  informed  that  sexual  intercourse 
is  just  as  important  to  her  as  to  him,  and  the  lack  of  it 
is  just  as  injurious  to  her  as  to  him.  He  should  be  in- 
formed that  it  is  just  as  necessary  for  his  wife  to  "come" 
— that  is,  to  have  complete  orgasm — as  it  is  for  him;  and 
that  to  simply  excite  his  wife  either  by  withdrawal  or  too 
soon  removal  of  his  penis,  and  to  leave  her  moaning  with 
an  excited  but  uncompleted  passion,  is  sure  to  lead  to  trouble. 
The  husband  should  be  taught  that  before  commencing 
coitus  his  wife  should  be  fully  awakened  and,  by  all  the 
arts  of  love  and  affection,  be  stimulated  into  passion,  so 
that  during  the  act  she  should  if  possible  be  as  passionate 
as  he  is.  If  he  should  get  through  before  her,  he  should 
not  merely  consider  himself  and  his  own  comfort,  but  leave 
his  organ  in  her  vagina  until  she  has  had  her  orgasm.  He 
should  be  the  true  lover  and  not  merely  the  beast.  If  suf- 
fering from  impotence,  or  rapid  ejaculation,  these  should 
receive  the  proper  treatment.  He  should  be  taught  that 
coitus  interruptus  is  not  normal  coitus,  and  is  sure  to  react 
injuriously  on  both  parties.  If  all  men  were  properly 
instructed,  there  would  be  less  complaint  of  frigidity  of  the 
wife  on  the  part  of  the  husband,  and  also  less  complaint  on 
the  part  of  the  wife  that  sexual  intercourse  only  results  in 
pregnancies  for  her, 


CHAPTER  IV. 

IMPOTENCE  IN  THE  MALE. 

Definition.  Impotence  and  sterility.  Organic  impotence.  Defini- 
tion. Etiology  and  pathology.  Symptoms.  Diagnosis.  Prognosis. 
Treatment.     Rudimentary  penes. 

Definition. — Impotence  in  the  male  is  that  condition  in 
which  the  man  is  unable  to  perform  the  sexual  act.  It 
may  be  either  complete  or  partial.  In  the  former  he  is 
absolutely  unable  to  perform  the  act,  while  in  the  latter  he 
may  still  be  able  to  have  a  more  or  less  complete  erection, 
but  either  the  erection  is  so  weak  that  it  subsides  at  the 
moment  of  intromission  or  even  before  intromission,  or,  in 
addition  to  this  weakness,  there  may  exist  such  a  hyperir- 
ritability  of  the  parts  or  sexual  centers  that  the  entire  pro- 
cess of  erection  and  ejaculation  lasts  but  a  very  short  while 
and  is  finished  at  the  momicnt  of  intromission,  or  a  very 
short  while  after  intromission,  or  even  before  the  penis  has 
had  an  opportunity  to  enter  the  vagina. 

Impotence  in  the  male  must  be  strictly  differentiated 
from  sterility  in  the  male.  In  sterility  there  is  an  impos- 
sibility of  impregnating  the  female,  while  in  impotence 
there  is  an  impossibility  of  performing  the  sexual  act.  The 
sterile  man  is  not  necessarily  impotent.  He  may  be  fully 
able  to  properly  perform  the  sexual  act,  but,  on  account 
of  an  old  double  epididymitis  with  occlusion  of  both  vasa, 
not  one  drop  of  his  testicular  secretion  can  reach  his  penis. 
In  bad  cases  of  hypospadias  and  epispadias  the  man  may 
have  proper  erection  and  ejaculation,  but,  on  account  of 

(55) 


66  Disorders  of  the  Sexual  Function. 

the  abnormal  opening  of  his  urethra,  not  one  drop  of  his 
semen  enters  the  vagina,  and  steriHty  is  the  result.  On  the 
other  hand,  it  is  also  possible  for  a  man  who  is  partially- 
impotent  not  to  suffer  from  sterility.  He  may  have  pre- 
mature or  very  rapid  ejaculation  and  only  be  able  to  deposit 
his  semen  at  the  very  entrance  of  the  vagina,  without  even 
real  intromission,  and  still  pregnancy  may  result.  As  a 
general  rule,  however,  the  impotent  man  is  also  sterile, 
inasmuch  as  (except  in  very  exceptional  cases)  he  is  unable 
to  deposit  his  semen  deep  enough  into  the  female  genitalia 
to  cause  impregnation. 

I  believe  the  old  classification  of  impotence  into  impoten- 
tia  coeundi,  and  impotentia  generandi,  the  former  designating 
impotence  of  coition  and  the  latter  impotence  of  impregna- 
tion, has  been  the  cause  of  much  confusion.  It  is  far  better 
to  limit  the  term  "impotence"  to  define  impossibility  of 
performing  the  sexual  act,  and  "sterility"  to  impossibility 
of  impregnation. 

Impotence  may  be  classified,  according  to  its  pathology, 
into  (I)  Organic  Impotence,  (II)  Functional  Impotence, 
and  (III)  Psychic  Impotence. 

I.  ORGANIC  IMPOTENCE. 

Definition. — Organic  impotence  is  that  condition  in 
which  the  impotence  is  due  to  some  anatomical  defect  in 
the  sexual  organs. 

Etiology  and  Pathology. — Any  condition  which  may 
cause  a  lack  of  development  of  any  portion  of  the  sexual 
apparatus,  or  an  atrophy  or  degeneration  of  these  parts,  is 
an  etiological  fac<-or  in  this  form  of  impotence.     Among 


JI'  (^I^A^^^^-lhM' 


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Impotence  in  the  Male.  57 


such  conditions  may  be  mentioned  mumps,  which  in  bad 
cases  may  cause  a  complete  atrophy  of  both  testicles  so 
early  in  life,  as  to  preclude  the  development  of  sexual  powers. 
Injuries  or  other  conditions  which  may  result  in  complete 
castration  before  puberty  will  also  interfere  with  the  de- 
velopment of  sexual  sense  and  power.     Lack  of  develop- 
ment or  absence  of  the  penis,  either  congenital  or  by  destruc- 
tion of  this  organ  through  injury  or  disease,  must  resuh  in 
impotence,  although  the, sexual  desire  may  still  be  present. 
In  certain  forms  of  spinal  syphilis  as  well  as  in  locomotor 
ataxia  the  erection  centers  may  be  completely  destroyed 
and  impotence  will  follow.    Injuries  to  the  spinal  cord  may 
cause  impotence,  either  by  direct  destruction  of  the  erec- 
tion center  or  by  destruction  of  those  fibers  which  convey 
the  impulses  to  and  from  these  centers  to  the  peripheral 
organs.     In  the  same  way  injuries  to  the  cerebrum  may 
likewise  cause  impotence.     Severe  injuries  to  the  urethra 
may  result  in  such  distortion  and  shortening  of  the  urethra 
that  it  is  impossible  to  stretch  normally  in  erection,  result- 
ing in  curvature  of  the  penis  and  impotence.     Cicatricial 
contractions  of  the  tissues  of  the  penis,  as  the  result  of 
burns  or  other  traumas,  may  also  mechanically  interfere 
with  erection. 

It  must  however  be  emphasized  that  v/bile  complete 
absence  of  the  penis  must  of  necessity  lead  to  impotence, 
yet  a  small,  undeveloped  penis  does  not  necessarily  lead  to 
that  result.  There  are  many  cases  on  record  in  which  men 
with  almost  rudimentary  penes  were  able  to  perform  the 
sexual  act  more  or  less  properly.  The  same  may  be  said 
of  hypertrophy  of  the  penis.     There  are  indeed  very  few 


'58  Disorders  of  the  Sexual  Function. 


penes,  no  matter  how  large,  for  which  intromission  is  not 
possible.     Sturgis^^^  gives  an  extreme  case  (mentioned  by 
Hyrtl)   of  a  Swiss  smith  whose  penis  was  the  size  of  a 
child's  body.     Of  this  case  Sturgis  remarks  ''Clearly  such 
an  unlucky  wretch  would  be  compelled  to  a  life  of  celibacy, 
for  no  mortal  vagina  would  be  capable  of  receiving  such 
a  membrum  virile."     It  is  also  remarkable  how  much  of 
the  penis  can  be  destroyed  by  ulceration  or  other  causes 
without  resulting  in  impotence.    Among  other  penile  curios- 
ities which  may  have  that  effect  may  be  mentioned  peno- 
scrotal fusion,  and  bifid  penis,  while  neoplasms  of  the  penis, 
may  from  their  size  render  the  person  impotent.     Plastic 
exudates  either  in  the  corpora  cavernosa  or  corpus  spongi- 
osum may  also  interfere  with  erection.    Shortness  of  f renum 
has  likewise  so  interfered  with  erection  that  impotence  re- 
sulted until  relieved  by  operation. 

Among  other,  conditions  interfering  with  intromission 
may  be  mentioned  enormous  hydrocele,  large  scrotal  hernia 
and  elephantiasis.     In  these  conditions  the  penis  may  be  so 
enveloped  by  the  surrounding  parts  that  it  appears  absent, 
and  cannot  protrude  enough  for  intromission  even  in  erec- 
tion.    After  gangrene  of  the  penile  integument  or  after 
destruction  of  portions  of  the  penis  from  chancroidal  ulcer- 
ations,'  scarring   and   contraction  may  result  to   such  an 
extent  as  to  interfere  with  erection.     Among  the  rare  con- 
ditions causing  organic  impotence  may  be  mentioned  horny 
growths  of  the  penis,  elephantiasis  of  the  penis  and  scro- 
tum, preputial  calculi,  ossification  of  the  penis,  and,  lastly, 
fracture  of  the  penis,  either  as  a  result  of  coitus  or  of 
"breaking"  a  chordee. 


jj),^  A^.^SAaJ^" 


Impotence  in  the  Male.  59 


Walsh/23  in  the  American  Journal  of  Urology  for  May, 
1913,  reports  an  unusual  condition  causing  impotence  in 
the  male.  In  these  cases  erection  was  normal,  but  there 
was  absolutely  no  ejaculation.  Nocturnal  pollutions,  how- 
ever, did  occur,  and  massage  of  the  prostate  produced  a 
normal-appearing  fluid  which  contained  actively  motile 
spermatozoa.  On  attempting  to  introduce  the  posterior 
urethroscope  an  obstruction  was  experienced  in  the  pos- 
terior urethra.  The  posterior  urethra  was  dilated  by  sounds 
until  the  urethroscope  could  be  introduced.  It  was  then  seen 
that  there  had  previously  existed  a  band  of  tissue  connect- 
ing the  two  ejaculatory  ducts  which  was  torn  by  the  sound 
dilatations.    After  this  the  patients  became  perfectly  normal. 

The  explanation  given  by  Walsh  is  that,  during  erec- 
tion, the  posterior  urethra,  or  at  least  that  portion  adjacent 
to  the  ejaculatory  ducts,  should  be  capable  of  distention  to 
receive  the  contents  of  the  ducts.  On  account  of  the  pres- 
ence of  the  band  of  tissue,  hov/ever,  this  was  impossible. 
The  fluid  could  not  enter  the  urethra  and  ejaculation  was 
impossible.  During  sleep,  however,  when  the  penis  is  not 
at  all  or  only  partially  erected,  there  is  no  tension  put  on 
the  urethra  causing  the  mouths  of  the  ejaculatory  ducts  to 
close,  and  consequently  the  seminal  fluid  escapes  easily.  The 
same  held  good  in  massage  of  the  prostate. 

Horse-back  riding  as  well  as  bicycle  riding  may  cause 
impotence  if  done  excessively  and  for  a  prolonged  period 
of  time.  Moderate  exercise  in  this  regard  has  no  such 
effect. 

Symptoms.  — The  chief  symptom  is  the  impotence  itself. 
In  many  cases  partial  erection  can  take  place,  and  in  some 


60  Disorders  of  the  Sexual  Function. 

cases  erection  takes  place,  but  is  exceedingly  painful.  As  a 
result  of  any  form  of  impotence  there  often  follow  a  whole 
train  of  nervous  symptoms,  in  some  cases  bordering  on 
insanity  and  not  infrequently  leading  to  suicide.  But  as 
these  symptoms  are  common  to  all  forms  of  impotence, 
whether  organic,  functional,  or  psychic,  they  will  be  de- 
scribed later  on. 

Diagnosis. — The  main  point  in  the  diagnosis  is  to  find 
the  original  cause,  for,  after  all,  impotence  is  but  a  symp- 
tom of  some  other  disease. 

Prognosis.  — This  depends  upon  the  etiological  factor, 
and  the  possibility  of  removing  the  impediment  by  operation 
or  other  means.  Many  of  the  causes  just  mentioned  are 
very  easily  remedied  by  operation,  while  others  are  clearly 
beyond  our  control. 

Treatment. — A  glance  at  the  various  etiological  factors 
will  indicate  the  method  of  treatment  in  many  of  these  cases. 
One  point  should  be  emphasized,  however,  in  the  manage- 
ment of  cases  with  small  or  rudimentary  penes.  For  some  of 
these  cases,  ingenious  apparatus  have  been  invented  enabling 
the  penis  to  enter  the  vagina,  especially  if  the  woman  be 
instructed  to  take  an  astringent  douche  before  coitus.  It 
has  also  happened  that  after  frequent  coitus  with  the  aid 
of  such  apparatus,  the  penis  has  actually  increased  in  size 
and  developed  sufficiently  for  coitus  without  any  artificial 
aid. 


^UUMj' 


CHAPTER  V. 

n.  FUNCTIONAL  IMPOTENCE. 

Definition.  Sexual  vigor  a  relative  term.  Etiology  and  pathology. 
Libido,  erection,  ejaculation,  orgasm.  Mechanism  of  coitus  in  the 
end-organs.  Theory  of  verumontanum  in  coitus.  Nervous  mechanism 
of  coitus.  Pathology  of  impotence  from  excessive  coitus.  Pathology 
of  coitus  interruptus.  Patholog>-  of  impotence  following  masturba- 
tion. Gonorrhea  and  impotence.  Pathology  of  ungratified  sexual 
excitement  as  a  cause  of  impotence.  Cases  with  obscure  pathology. 
Author's  opinion.  Symptoms.  Disturbance  of  the  libido.  Disturbance 
of  erection  and  ejaculation.  Author's  opinion  on  paralytic  impotence. 
Disturbance  in  the  orgasm.  Cases  of  congenital  weakness.  Impor- 
tance of  recognizing  the  etiology  in  the  former  class.  Local  symptoms 
accompanying  impotence.  General  symptoms.  Psychic  symptoms. 
Diagnosis.  Importance  of  examining  wife.  Importance  of  thinking  of 
organic  nervous  conditions.  Prognosis.  Treatment.  Intelligent  treat- 
ment of  posterior  urethra.  Importance  of  posterior  endoscopy.  Sex- 
ual stimulants.     Original  experimentation. 

Definition. — Functional  impotence  is  that  form  of  im- 
potence in  which  there  exists  no  gross  pathological  change 
in  the  structure  of  the  sexual  apparatus,  but  in  which  the 
mechanism  of  copulation  is  disturbed  through  an  interfer- 
ence with  the  function  of  the  sexual  centers  or  the  nerves 
and  peripheral  end-organs. 

In  this  class  of  cases  there  is  found  neither  the  absence 
of  important  organs  nor  the  marked  pathological  conditions 
mentioned  under  Organic  Impotence.  Generally  speaking, 
the  sexual  organs  are  sound.  I  have  emphasized  the  word 
"gross,"  to  indicate  that  the  condition  is  not  without  a 
pathological  basis,  and  that,  in  a  not  infrequent  number  of 
cases,  the  endoscope  will  reveal  areas  of  congestion,  inflam- 
mation or  even  erosions  in  the  posterior  urethra,  and  in 

(61) 


62  Disorders  of  the  Sexual  Function. 

many  of  them  an  examination  will  show  congestion  of  the 
prostate  and  seminal  vesicles.  The  condition  must  be  con- 
sidered functional,  however,  because  these  lesions  do  not 
act  by  imposing  a  mechanical  impediment  to  either  ejacu- 
lation or  erection,  but  act  purely  reflexly  upon  the  sexual 
centers. 

Impotence  is  physiological  before  puberty  as  well  as  in 
old  age.  It  may  also  be  considered  physiological  after  a 
normal  coitus,  although  some  men  are  able  to  repeat  the  act 
many  times. 

It  must  be  emphasized,  however,  that  potency,  or  sex- 
ual vigor,  is  a  relative  term,  and  that  there  are  some  men 
who  can  indulge  in  coitus  every  night  and  keep  this  up  for 
a  very  long  time,  while  others  can  only  indulge  once  or  twice 
a  week.  A  man  belonging  to  the  latter  class  would  by  no 
means  be  considered  impotent  or  suffering  from  sexual 
weakness.  We  must  therefore  take  the  entire  history  of 
the  case  into  consideration  before  deciding  whether  a  man 
is  losing  his  sexual  vigor. 

Etiology  and  Pathology. — ^The  normal  act  of  coitus 
consists  in  the  following  sequence  of  events,  and  in  the  har- 
monious relationship  of  the  various  factors.  In  the  first 
place  there  must  be  the  libido,  or  desire  for  sexual  inter- 
course; then  there  must  be  the  erection  of  the  penis,  then 
ejaculation,  and  finally  the  orgasm.  The  absence  or  dis- 
turbed relationship  of  any  of  these  factors  constitutes  im- 
potence, either  partial  or  complete.  Moreover,  not  only 
must  the  normal  sequence  of  events  occur,  but  also  the 
relative  time  for  each  factor  must  be  observed  for  normal 
coitus.    Thus,  if  ejaculation  comes  too  quickly,  before  erec- 


Impotence  in  the  Male.  63 

tion  is  complete,  or  too  slowly, — that  is,  long  after  erection 
has  subsided, — or  if  erection  does  not  last  long  enough,  or 
if  the  whole  process  of  coitus  goes  very  quickly,  or  any 
other  condition  in  which  the  time  allowed  to  each  factor 
is  relatively  out  of  proportion,  impotence  may  be  said  to 
exist. 

In  order  to  understand  the  pathology  of  organic  im- 
potence, as  well  as  the  influence  of  various  etiological  factors 
in  the  production  of  the  same,  it  is  necessary  to  have  a 
clear  idea  of  the  mechanism  of  normal  coitus.  This  will 
be  considered  under  two  heads :  First,  the  mechanism  and 
sequence  of  events  as  they  take  place  in  the  end-organs 
{i.  e.,  the  testicles,  epididymi,  vas,  seminal  vesicles,  ejacu- 
latory  ducts,  prostate  and  penis),  and  secondly,  the  sequence 
of  events  in  the  sexual  centers  and  nerves. 

Mechanism  of  Coitus  in  the  End-organs. — As  soon  as  the 
libido  is  aroused,  either  by  the  sight  or  contact  of  a  woman, 
or  from  peripheral  irritation  of  the  penis,  an  impulse  is 
sent  to  the  erection  center  in  the  lumbar  portion  of  the 
spinal  cord,  which  arouses  it  into  activity.  The  center,  now 
aroused,  sends  impulses  to  the  arteries  and  muscular  struc- 
ture of  the  penis.  In  the  quiescent  state,  the  arteries  of 
the  penis  are  in  a  state  of  contraction,  allowing  no  more 
blood  than  is  necessary  for  nourishing  the  parts.  The 
musculature  is  also  in  a  contracted  state,  thus  obliterating  all 
trabeculation.  The  impulses  which  arq  sent  out  from  the 
erection  center  are  vasodilator  in  character,  thus  allowing 
the  arteries  to  dilate  and  fill  up  with  blood;  they  have  also 
the  effect  of  relaxing  the  musculature,  and  so  causing  the 
formation  of  large  trabecular  spaces.    As  a  result,  the  cor- 


64  Disorders  of  the  Sexual  Function. 


pora  cavernosa  become  engorged  with  blood.  The  muscles 
surrounding  the  penis,  however,  are  thrown  into  contrac- 
tion, which  has  the  effect  of  compressing  the  veins  of  the 
penis,  and  the  resulting  congestion  adds  still  further  to  the 
engorgement  of  the  parts.  The  fibrous  investment  of  the 
penis  is  put  on  the  stretch  by  the  increase  in  volume  of  the 
organ,  and  this  also  adds  to  the  compression  of  the  veins 
and  the  consequent  engorgement  of  the  penis.  The  influx 
of  blood,  however,  has  more  to  do  with  erection  than  the 
compression  of  the  veins ;  this  is  proven  by  the  fact  that  in 
priapism,  which  may  continue  for  a  very  long  time,  some- 
times for  days  and  even  weeks,  no  gangrene  results. 

As  soon  as  the  organ  becomes  rigid,  the  action  of  its 
suspensory  ligament  aided  by  the  erector  penis  and  the  ac- 
celerator urin^  muscles  causes  it  to  become  elevated.  Fin- 
ally all  the  perineal  muscles  come  into  play  to  complete  the 
erection,  and  now  the  organ  is  hard  and  tense.  The  testi- 
cles at  the  same  time  are  drawn  close  to  the  abdomen  through 
the  contraction  of  the  dartos  and  the  muscular  fibers  of  the 
cord. 

As  a  result  of  the  active  congestion,  the  mucous  glands 
of  the  urethra  pour  into  the  urethra  an  alkaline  secretion 
to  neutralize  any  acid  urine  which  may  have  been  left 
therein,  and  which  would  be  inimical  to  the  vitality  of  the 
spermatozoa. 

As  a  result  of  the  muscular  action  upon  the  testicles, 
aided  by  the  peristalsis  of  the  musculature  of  the  epidid- 
ymis and  the  vas,  the  spermatozoa  are  pressed  out  of  the 
epididymis  into  the  vas  and  into  the  ampulla. 

As  coitus  proceeds  the  contents  of  the  seminal  vesicles 


i 


Impotence  in  the  Male.  65 

are  squeezed  by  muscular  action  into  the  ejaculatory  ducts, 
the  muscles  of  the  prostate  also  contract,  squeezing  out  the 
prostatic  secretions,  and  at  the  height  of  the  orgasm  the 
contents  of  the  seminal  vesicles  mixed  with  the  spermatozoa, 
which  have  just  been  extruded  from  the  testicles,  are  pushed 
through  the  ejaculatory  ducts  into  the  posterior  urethra, 
where  they  mix  with  the  prostatic  secretion,  and  the  entire 
product,  the  semen,  is  driven  from  the  bulbous  urethra 
through  the  penis  by  the  Contraction  of  the  entire  perineal 
group  of  muscles.  The  squeezing  of  the  contents  of  the 
seminal  vesicles  plus  the  testicular  contents  into  the  pos- 
terior urethra  causes  the  extreme  of  pleasurable  feeling 
known  as  the  orgasm. 

It  may  be  noticed  that,  in  the  above  description  of  the 
physiology  of  coitus,  I  have  not  mentioned  that  the  semen, 
after  it  has  reached  the  posterior  urethra,  is  prevented 
from  going  into  the  bladder  by  the  erection  of  the  verumon- 
tanum,  which  by  its  erection  closes  off  the  posterior  ure- 
thra from  the  bladder.  This  statement  has  been  passed  on 
from,  I  do  not  know  how  many  years  back,  until  the 
present  time,  and  may  be  found  even  in  some  of  our  latest 
textbooks.  Like  so  many  statements,  it  has  simply  been 
copied  from  one  work  into  another  without  investigation 
or  challenge. 

Since  the  advent  of  modern  improved  posterior  ure- 
throscopes, however,  it  has  been  noticed  that  in  many  cases 
the  verumontanum  may  be  exceedingly  small;  in  fact,  I 
have  seen  it  in  some  cases  no  bigger  than  a  pimple,  and 
nevertheless  no  interference  with  the  act  of  coitus  is  experi- 
enced.   Moreover,  Rytina^^^  has  reported  a  series  of  cases 


66  Disorders  of  the  Sexual  Function. 

in  which  for  various  reasons  he  had  removed  the  entire 
verumontanum,  without  any  sexual  difficulty  being  experi- 
enced by  the  patients. 

Nervous  Mechanism  of  Coitus. — In  the  description  of 
the  sequence  of  events  which  take  place  during  normal  and 
pathological  coitus,  in  the  sexual  centers  and  nerves,  I  have 
closely  followed  that  given  by  Groag^^  as  being  of  especial 
clearness. 

We  may  represent  the  various  conditions  diagrammatic- 
ally  as  follows  (Figs.  1-4).  From  C  (cerebrum,  i.  e., 
libido)  impulses  are  sent  to  R  (erection  center),  which 
sends  them  to  the  dilator  nerves  until  complete  erection 
results  {i.  e.,  dilatation  of  blood-vessels  of  penis,  etc.)  Now 
R  receives  from  P  (glans  penis  during  friction)  continuous 
new  impulses  which  serve  to  strengthen  and  keep  up  the 
erection.  Besides  sending  the  receiving  impulses  to  the 
dilator  nerves,  R  has  also  the  function  of  keeping  back 
a  part  of  the  impulses  it  receives  until  the  cells  of  the 
erection  center  are  filled  to  their  utmost  tension  (Reitz- 
spannungsvermogen),  and  then  only  to  send  the  impulses 
to  £1  (sympathetic  ejaculation  center,  which  causes  the 
expulsion  of  the  secretions  of  the  sexual  glands),  and  also 
to  £2  (spinal  ejaculation  center,  which  controls  the  striated 
muscular  fibers).  The  impulses  that  come  from  P  \.o  R 
(through  friction  of  the  glans  penis)  may  be  weaker,  in 
proportion  as  the  impulses  that  come  from  V  (distended 
seminal  vesicles)  are  stronger.  In  other  words,  with 
markedly  distended  seminal  vesicles  we  can  get  normal  co- 
itus even  if  there  is  less  friction  of  the  glans  penis,  for 
enough  impulses  are  coming  from  the  seminal  vesicles  to 


Impotence  in  the  Male. 


Diagrammatic   scheme   of   the   nervous   mechanism    of    normal    coitus, 
impotence,  and  pollutions.     (After  Groag.) 

C,  cerebrum;  R,  erection  center;  £i,  sympathetic  ejaculation  center 
(which  causes  the  expulsion  of  the  secretions  of  the  sexual  glands)  ; 
£2,  spmal  ejaculation  center  (which  controls  the  striated  muscular 
fibers)  ;  P,  glans  penis ;  V,  seminal  vesicles.  The  single  arrow  indi- 
cates an  ordinary  impulse;  the  double  arrow,  a  verj^  strong  impulse. 
I  he  transverse  lines  in  R,  in  Figs.  1,  2,  and  3,  indicate  that  R  sends 
out  impulses  to  E^  and  £0  only  after  having  been  completely  filled  up 
with  impulses,  while  in  Fig.  4  we  see  that  R  sends  them  out  before  it 
IS  completely  filled  up  with  impulses. 


68  Disorders  of  the  Sexual  Function. 


fill  up  R.    As  soon  as  R  is  so  filled  up  with  impulses  from 
C,  P  and  V  that  they^  overflow  to  E^  and  E^,  ejaculation 

occurs. 

We  may  now  briefly  describe  the  nervous  mechanism 
of   normal   coitus   according   to   the   above   diagrammatic 
scheme,  and  later  on  the  pathology  of  impotence  according 
to  the  same  scheme.    The  seat  of  the  libido  is  in  the  cere- 
brum, and  it  may  be  aroused  by  the  sight  of  a  woman, 
contact  with  a  woman,  or  by  caressing,  "spooning,"  erotic 
literature,  or  through  any  of  the  senses,  and  in  numerous 
other  and  different  ways.     Once  the  libido  is  aroused,  and 
the  man  is  prepared  for  normal  coitus,  an  impulse  is  sent 
from  the  cerebrum  (C)  to  the  erection  center  (R)  m  the 
lumbar  enlargement  of  the  spinal  cord.     This  center  sends 
impulses  through  the  dilator  nerves  to  the  penis,  as  a  result 
of  which  impulses  the  penis  becomes  engorged  with  blood 
and  erection  occurs  as  previously  described.     As  the  penis 
enters  the  vagina,  the  friction  of  the  glans  penis  (F)  sends 
additional  impulses  to  the  erection  center  (R).    The  erec- 
tion center  (i?)  is  also  getting  impulses  from  the  distended 
seminal  vesicles  (F).     In  the  normal  condition  of  affairs, 
it  is  only  when  the  erection  center  (7?)  has  been  completely 
filled  up  with  these  impulses  from  the  cerebrum   (C),  the 
penis  (F)  and  the  seminal  vesicles  (F),  that  it  sends  out 
impulses  to  the  ejaculation  centers  (E^  and  E^)  and  allows 
ejaculation  to  take  place.     In  other  words,   the  erection 
center   (R)   has  two  functions:  first,  to  receive  impulses 
from  the  cerebrum   (C),  the  penis   (F)   and  the  seminal 
vesicles   (F),  and,  secondly,  to  hold  back  these  impulses 
till  the  proper  time  and  then  send  them  to  the  ejaculation 


i 


Impotence  in  the  Male.  69 

centers  (£i  and  £2)?  so  that  ejaculation  should  come  just 
at  the  proper  time  and  not  too  soon. 

I  have  gone  somewhat  minutely  into  this  diagrammatic 
description  of  the  nervous  mechanism  of  normal  coitus 
because  it  is  only  by  having  a  clear  idea  of  this  mechan- 
ism that  we  are  enabled  to  understand  the  pathology  of 
impotence.  We  will  now  take  up  the  various  etiological 
factors,  and  show  how  they  cause  impotence,  by  disturb- 
ing one  or  more  of  the  functions  of  the  above  factors  of 
normal  coitus,  or  by  disturbing  the  relationship  c>f  the 
various  factors.  The  various  etiological  factors  to  be  dis- 
cussed will  be :  acute  impotence  from  excessive  coitus, 
coitus  interruptus,  (withdrawal),  masturbation,  sequelae  of 
gonorrhea,  ungratified  sexual  excitement  (prolonged  spoon- 
ing, etc).  The  pathology  of  many  of  these  etiological 
causes  will  be  found  to  be  very  similar. 

Pathology  of  Impotence  from  Excessive  Coitus. — This  is 
the  simplest  form  of  fimctional  impotence  and  consists  in 
an  exhaustion  of  the  erection  center  (i?).  If,  shortly  after 
a  completed  coitus  a  repetition  of  the  act  is  attempted, 
stronger  excitation  is  necessary  to  accomplish  erection,  and 
still  stronger  and  more  intensive  to  produce  ejaculation. 
W'ith  every  repeated  attempt  at  coitus,  the  necessary  in- 
crease in  excitation  rises  in  proportion  with  the  number  of 
attempts.  This  can  be  readily  appreciated  from  our  dia- 
grammatic schemiC.  After  one  or  several  attempts  at  coitus, 
the  seminal  vesicles  are  empty,  and  the  erection  center  {R) 
thus  receives  no  impulses  from  them  (F),  the  friction  of 
the  glans  penis  during  coitus  is  also  less  and  less  pow^erful, 
and  so  few  impulses  come  from  there  (P),  and  the  erec- 


70  Disorders  of  the  Sexual  Function. 


tion  center  (R)  must  therefore  depend  almost  entirely  upon 
the  impulses  it  receives  from  the  cerebrum  (C)  in  order  to 
cause  erection  and  also  in  order  to  get  enough  impulses 
to  become  distended  so  that  it  can  send  them  out  to  the 
ejaculation  centers  {E^  and  £2)  for  ejaculation  to  take 
place.  The  erection  center  (i?)  is  now  in  a  state  of  abso- 
lute exhaustion,  and  needs  a  certain  length  otf  time  to 
recuperate.  After  this  recuperation,  everything  is  normal 
again.  This  is  the  acute  form  of  impotence  in  a  normal 
person.  Finally  the  most  intensive  excitations  fail  to  cause 
an  erection  and  naturally  also  an  ejaculation.  The  oft- 
repeated  acts  or  attempts  at  coitus  also  have  the  effect  of 
exhausting  the  center  (R)  itself. 

Pathology  of  Coitus  Interniptus. — In  the  normal  con- 
dition of  affairs,  as  soon  as  the  libido  has  been  aroused, 
and  the  impulse  has  been  sent  from  the  cerebrum  (C)  to 
the  erection  center  in  the  lumbar  enlargement  of  the  spinal 
cord  (R),  thus  arousing  it  into  activity,  there  occurs  a 
normal  working  hyperemia  of  this  center.  This  working 
hyperemia  is  being  increased  during  coitus  by  continuous 
stimulation  of  impulses  from  the  glans  penis  (P)  and 
seminal  vesicles  (F).  As  soon  as  this  center  has  been 
stimulated  to  its  maximum,  it  sends  its  impulses  to  the 
ejaculation  centers  (£1  and  E2),  ejaculation  takes  place, 
and  with  this  event  there  results  a  diminution  and  final 
disappearance  of  the  hyperemia  of  the  erection  center. 
Normally,  there  now  ensues  a  condition  of  rest  for  several 
days,  and  the  center  has  plenty  of  time  to  recuperate.  Sex- 
ual intercourse  is  not  generally  indulged  in  for  several  days, 
and  the  erection  center  is  not  bothered  with  stimulating 


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(T  ^-'l.-?.  > r«r 


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Impotence  in  the  Male.  71 

impulses  from  either  the  cerebrum,  seminal  vesicles,  or 
other  sources.  (In  this  description  I  leave  out  of  account 
the  increased  sexual  activity  which  follows  the  first  months 
of  wedded  life.)  Normally,  also,  the  same  condition  holds 
good  in  the  end-organs.  During  coitus  the  seminal  ves- 
icles, which  were  distended,  empty  themselves  more  or  less 
completely,  the  prostatic  urethra,  which  during  coitus  is 
also  hyperemic,  becomes  deplethorized  with  the  normal  act 
of  ejaculation,  and  the  parts  soon  regain  their  normal  con- 
dition of  blood-supply. 

What  is  the  condition  of  affairs  in  coitus  interruptus? 
The  following  description  of  the  pathology  does  not  apply 
to  one  single  act  of  withdrawal,  but  only  to  those  cases 
where  the  practice  had  been  kept  up  for  a  long  time,  months 
or  years. 

With  the  interruption  of  the  act  of  coitus,  ejaculation 
is  incomplete,  the  erection  center  {R)  is  not  thoroughly 
deplethorized,  on  account  of  the  incomplete  ejaculation.  It 
thus  remains  more  or  less  hyperemic.  The  seminal  vesicles 
do  not  so  completely  empty  themselves  as  in  normal  coitus, 
and  they  consequently  become  distended  much  sooner  than 
after  a  normal  coitus,  and  the  desire  for  coitus  is  thus 
experienced  much  earlier  than  after  a  normal  coitus.  The 
hyperemic  condition  of  the  prostatic  urethra,  which  under 
normal  conditions  disappears  with  the  complete  ejacula- 
tion, remains  more  or  less  in  part,  and  after  the  practice 
had  been  kept  up  for  a  long  time,  a  condition  of  chronic 
congestion  of  these  parts  supervenes.  The  frequent  dis- 
tention of  the  seminal  vesicles  leads  to  increased  desire  for 
coitus,  and  increased  coitus  still  further  keeps  up  the  hyper- 


^2  Disorders  of  the  Sexual  Function. 

emic  condition  of  the  erection  center,  leaving  less  time  for 
it  to  recover  itself.  The  chronic  congestion  of  the  pros- 
tatic mucous  membrane  has  the  effect  of  continually  sending 
impulses  to  the  sexual  centers,  even  in  the  absence  of  coitus, 
and  thus  the  hyperemic  erection  center  is  being  constantly 
bombarded  with  impulses  until  it  is  at  first  in  a  state  of 
hyperirritability  and  finally  of  exhaustion.  \\"hile  in  a  state 
of  hyperirritability,  the  slightest  impulse  it  receives  from  the 
cerebrum,  at  the  very  commencement  of  coitus,  causes  it 
to  respond  so  rapidly  that  it  at  once  sends  the  impulse 
to  the  ejaculation  centers  and  ejaculation  takes  place  at  the 
very  commencement  of  coitus,  just  as  the  penis  has  entered 
the  vagina  (rapid  ejaculation),  and  in  a  later  stage,  even 
before  the  penis  has  had  an  opportunity  to  enter  the  vagina 
(premature  ejaculation).  In  other  words  the  center  has 
lost  its  power  to  hold  back  the  impulses  till  the  proper  time. 
This  is  graphically  illustrated  in  Fig.  4.  Finally,  the  center 
becomes  completely  exhausted,  and  fails  to  respond  to  any 
stimulus  either  from  the  cerebrum  or  other  sources;  it  re- 
fuses to  send  out  any  impulse  at  all,  and  thus  we  get  as  a 
final  stage,  not  only  no  ejaculation,  but  also  absence  of 
erection. 

It  is  very  Interesting,  if  we  take  a  careful  history  of 
one  of  these  cases,  how  the  symptoms  follow  exactly  the 
pathology  just  described.  We  first  get  a  history  of  rapid 
ejaculation,  less  and  less  time  is  consumed  in  the  coital 
act,  the  erections  may  however  still  be  strong;  then  we  get 
premature  ejaculation,  next  a  weakness  in  the  erections, 
the  patients  at  this  stage  complain  that  the  organ  "just 
about  gets  stiff,"  but  ejaculation  takes  place  at  once  with 


Impotence  in  the  Male.  73 

an  immediate  decline  of  the  erection,  and  finally,  as  a  last 
stage,  they  can  neither  get  erection  at  all  nor  any  ejacu- 
lation. We  note  that  there  is  nothing  mysterious  about  all 
this,  and  that  it  is  exactly  what  would  occur  in  any  other 
end-organ  under  similar  conditions. 

It  must  not  be  imagined,  however,  that  every  case  goes 
on  to  the  final  stage.  The  process  may  be  stopped  at  any 
stage  by  proper  treatment  and  a  discontinuance  of  the  prac- 
tice. The  length  of  time  necessary  to  reach  each  stage 
varies  considerably  in  different  individuals.  I  have  seen 
the  final  stage  reached  after  but  six  months  of  withdrawal 
and,  on  the  other  hand,  have  seen  patients  indulge  in  this 
practice  for  many  years,  before  any  ill-effect  was  noticed. 

Pathology  of  Impotence  following  Masturbation. — As  a 
matter  of  fact,  masturbation  is  very  seldom  an  etiological 
factor  in  impotence,  especially  when  we  consider  the  fre- 
quency of  masturbation.  The  man  who  has  never  suffered 
from  gonorrhea  and  finds  himself  impotent  is  very  apt, 
influenced  by  quack  literature,  to  blame  it  on  his  youthful 
errors,  errors  which  may  have  been  committed  ten  or  more 
years  previously.  I  will  not  deny,  however,  that  the  con- 
firmed, untreated  masturbator,  who  marries  with  the  idea 
that  sexual  intercourse  will  cure  his  masturbation,  may  find 
himself  impotent. 

The  pathology  in  these  cases  is  similar  in  many  respects 
to  that  of  withdrawal.  There  are  lacking,  however,  the 
impulses  from  distended  vesicles,  for  the  confirmed  mas- 
turbator does  not  give  his  vesicles  a  chance  to  become  dis- 
tended. The  chief  cause  of  the  exhaustion  of  the  erection 
center  {R)  comes  from  the  terribly  congested  prostate  and 


74  Disorders  of  the  Sexual  Function. 

prostatic  urethra,  which  has  been  for  years  bombarding 
the  center  with  reflex  impulses.  There  are  in  addition  two 
other  factors  which  contribute  toward  the  production  of 
impotency  in  these  cases.  One  is  that  the  frequent  manipu- 
lation of  the  penis  has  so  hardened  that  organ  that  the 
ordinary  friction  of  coitus  (even  if  he  is  able  to  get  his 
penis  into  the  vagina)  is  not  sufficient  to  arouse  the  more 
or  less  exhausted  sexual  centers.  Another  factor  comes 
into  play  where  psychic  masturbation  has  been  the  predom- 
inant type.  Here,  also,  the  sexual  centers  have  been  so 
dulled  that  it  is  only  the  most  vivid  picture  that  the  imag- 
ination can  conjure  up  which  will  be  sufficiently  strong  to 
arouse  them  into  action,  and  the  ordinary  acts  of  coitus  are 
not  sufficiently  powerful  to  arouse  either  the  desire  or  the 
ability  for  coitus. 

Pathology  of  the  Sequelae  of  Gonorrhea  as  a  Cause  of 
Impotence. — While  most  German  authorities  lay  great 
stress  upon  the  sequelae  of  gonorrhea  as  a  cause  of  im- 
potence, and  many  American  writers  follow  their  example, 
from  my  professional  experience,  I  cannot  at  all  subscribe 
to  this  opinion.  Here  again,  w^e  must  take  into  consider- 
ation that  gonorrhea  is  such  a  very  common  disease,  that, 
in  proportion  to  its  frequency,  impotence  is  a  very  infre- 
quent complication.  It  might  be  better  were  it  otherwise. 
If  every  man  attacked  with  gonorrhea  would  become  im- 
potent, for  a  while  at  least,  it  would  not  only  greatly  limit 
the  spread  of  the  disease,  but  would  also  be  a  most  power- 
ful deterrent  of  illicit  coitus. 

As  a  sequence  of  severe  and  especially  ill-treated  gonor- 
rhea, there  often  remain  granulations,  ulcerations,  vegeta- 


Impotence  in  the  Male.  75 

tions,  and  areas  of  congestion  and  erosions  in  the  posterior 
urethra,  especially  in  the  region  of  the  verumontanum. 
Sometimes,  there  is  also  present  a  chronic  inflammation  of 
the  prostate  and  seminal  vesicles,  which  are  found  to  be 
distended  with  purulent  and  other  secretions.  As  a  result 
of  these  pathological  conditions,  the  erection  center  is  being 
reflexly  bombarded  with  impulses  from  these  parts,  and 
irritability  and  exhaustion  of  the  center  may  result.  The 
treatment  of  the  posterior  urethra,  and  of  the  prostate  and 
seminal  vesicles,  generally  brings  about  a  cure. 

One  must  be  careful,  however,  in  interpreting  the  results 
of  treatment  in  these  conditions.  It  often  happens  that  the 
most  gross  pathological  conditions  which  are  seen  through 
the  posterior  urethroscope  are  not  the  cause  of  the  trouble, 
while  the  insignificant  areas  of  congestion  and  erosions  are. 
Very  often,  by  removing  the  gross  pathological  lesions,  we 
also  cure  by  the  same  application  or  cauterization  the  insig- 
nificant lesions,  and  are  thus  apt  to  consider  the  cure  due 
to  the  removal  of  the  gross  lesions.  As  a  matter  of  fact, 
however,  the  most  gross  lesions  may  be  seen  through  the 
posterior  urethroscope  without  in  any  way  giving  any  symp- 
toms, sexual  or  otherwise;  whereas,  in  other  cases,  a  very 
small  area  of  congestion  in  the  region  of  the  verumxontanum 
may  be  the  cause  of  the  most  marked  nervous  and  sexual 
symptoms. 

Pathology  of  Ungratified  Sexual  Excitement  as  a  Cause 
of  Impotence. — Ungratified  sexual  excitement  comes  into 
play  as  an  etiological  factor  in  impotence,  only  if  it  has 
existed  for  a  relatively  long  period  of  time.  Under  this 
heading  comes  especially  the  temporary  impotence  follow- 


Disorders  of  the  Sexual  Function. 


ing  long  engagements,  in  which  the  parties  see  each  other 
very  frequently  and  do  much  "spooning,"  and  this  goes  on 
for  a  period  of  one  or  more  years.    Very  often  the  man  is 
continent,  and  often  this  continence  is  put  down  by  some 
authors  as  a  cause  of  impotence.     As  a  matter  of  fact,  the 
man  in  this  case  is  not  all  continent,  in  the  scientific  mean- 
ing of  the  term;  he  only  abstains  from  the  coital  act  of 
intercourse.     W'e  must  remember  that,   scientifically,   the 
act  of  intercourse  begins  with  the  first  caresses  and  flirta- 
tions, and  that  coitus  is  but  the  final  stage  of  intercourse 
and  not  the  whole  thing.    The  man  in  this  case  really  goes 
through  all  the  preliminary  stages  of  intercourse,  stopping 
just  short  of  coitus.     In  many  of  these  cases,  the  man 
works  himself  up  in  his  passion  till  the  point  of  ejacula- 
tion, but  this  he  psychically  inhibits  -  till  the  erection  goes 
away,  and  then  he  starts  in  again.     It  is  in  this  way  the 
man  can  keep  up  the  spooning  process  for  hours  at  a  time. 
As  a  result  of  this  practice  kept  up  for  a  long  time,  we 
get  a  chronic  congestion  of  the  posterior  urethra,  just  as 
in  masturbation,  but  in  addition  we  have  the  presence  of 
an  almost  continuous  state  of  distention  of  the  seminal 
vesicles,  unless  they  are  relieved  by  an  occasional  pollution. 
As  a  result  of  all  this,  exhaustion  of  the  erection  center 
must  take  place  in  time,  in  the  same  manner  as  has  been 
described  in  the  previous  condition.    This  condition  is  rep- 
resented in  Fig.  3,  showing  the  double  arrows  (excessive 
strong  impulses)  coming  from  C  and  V. 

Finally,  as  etiological  factors  in  functional  impotence, 
we  must  mention  a  group  of  cases  in  which  the  pathology' 
is  obscure.     To  this  group  belong  impotence  from  diabetes 


.4/ 


LA, 


n 


)        ^ 


^ 


Impotence  in  the  Male.  11 

mellitus,  acute  febrile  conditions,  various  forms  of  acute 
and  chronic  poisoning,  chronic  debilitating  conditions,  and 
some  authors  include  herein  such  conditions  as  obesity  and 
chronic  nephritis. 

Concerning  chronic  nephritis  as  a  cause  of  impotence, 
Blum^*  remarks,  in  the  American  Journal  of  Urology, 
October,  19 12,  as  follows: — 

"We  find  in  many  textbooks  impotentia  coeundi  noted  in 
the  symptomatology  of  chronic  nephritis.  A  specific  inhibi- 
tion of  the  cerebrosexual  center  might  be  exerted  by  the 
urinary  poisons  retained  in  the  blood,  in  analogy  with  other 
chronic  intoxications.  I  myself  have  been  obliged  in  many 
cases,  in  which  the  patient  complained  of  diminution  or 
extinction  of  the  sexual  need,  to  declare  chronic  nephritis 
to  be  the  cause.  It  is  one  of  the  fundamental  rules  of  diag- 
nosis, that  we  examine  the  urine  in  every  case  of  impotence ; 
we  often  come  in  this  way,  to  the  great  and  painful  surprise 
of  the  patient,  to  an  explanation  of  the  fatal  symptom." 

I  doubt  very  much  whether  ordinary  nephritis  causes 
impotence.  As  a  matter  of  fact  I  know  of  many  men  with 
undoubted  chronic  nephritis  who  are  not  in  the  least  im- 
potent. I  have  in  mind  at  present  a  young  man  of  21, 
who  when  a  child  had  a  severe  attack  of  diphtheria  from 
which  he  almost  died  and  which  left  him  with  a  chronic 
nephritis,  with  very  high  arterial  tension,  etc.,  but  who  is 
very  passionate  sexually  and  not  in  the  least  impotent. 
Another  case  is  that  of  a  man  of  55  with  very  bad  kid- 
neys, who  still  enjoys  to  the  full  the  use  of  his  sexual 
apparatus.  The  author  quoted  above  cites  cases  where  the 
patient  complained  of  impotence,  and  where  a  urinary  ex- 


78  Disorders  of  the  Sexual  Function. 

amination  showed  the  presence  of  nephritis  which  had  been 
unknown  to  the  patient.  He  therefore  concludes  it  to  be 
the  cause  of  his  impotency.  Yet  time  after  time  has  it 
occurred  to  me,  as  well  as  probably  to  most  physicians, 
that  patients  came  for  entirely  different  complaints,  and  a 
routine  urine  examination  disclosed  an  unsuspected  nephri- 
tis, in  which  there  was  absolutely  no  suggestion  of  impotence 
present.  When  we  take  into  consideration  that  chronic 
nephritis  is  not  by  any  means  a  rare  disease,  we  must  not 
be  surprised  that  we  find  it  present  in  a  certain  percentage 
of  our  impotence  cases.  Of  course,  in  the  last  stages  of 
nephritis  with  marked  cachexia  and  uremic  symptoms,  this 
condition  may  cause  impotence  just  as  in  the  case  in  any 
other  dibilitating  disease,  but  I  am  convinced  that  ordinary 
cases  of  nephritis  are  not  responsible  for  impotence.  Blum 
himself  seems  to  correct  his  first  too  general  statement  when 
he  adds  at  page  551 :  "It  is  not  surprising  that  in  the  ad- 
vanced stages  of  nephritis  with  severe  uremic  phenomena 
and  outspoken  cachexia,  as  well  as  in  diabetes,  sexual 
impotence  should  occur,  when  the  exhaustion  of  the  patient 
has  reached  a  high  degree."  This  is  an  entirely  different 
state  of  affairs  from  that  of  an  apparently  healthy  man 
coming  into  the  office  for  impotence,  and  in  which  a  routine 
uranalysis  discloses  nephritis.  In  diabetes,  however,  it  is 
different.  Here  the  disease  itself  seems  to  be  the  direct 
cause  of  the  impotence. 

Many  authorities  put  down  oxaluria  as  a  cause  of  im- 
potence. I  have  paid  particular  attention  to  this  and  have 
had  the  urine  of  all  of  my  impotence  cases  examined,  not 
only  in  the  routine  manner,  but  especially  for  oxalates.   My 


'M 


Impotence  in  the  Male.  Y9 

experience  shows,  however,  that  oxaluria  is  only  very  infre- 
quently found  in  impotence. 

Symptoms  of  Functional  Impotence.  — The  symptoms  of 
impotence  may  be  divided  into  local  and  general. 

Local  Sjmiptoms. — I  have  previously  remarked  that,  for 
normal  coitus,  there  must  be  a  certain  sequence  of  events, 
which  must  proceed  in  perfect  harmony  and  proper  rela- 
tionship of  one  to  the  other.  These  events  are  the  libido, 
the  erection,  the  ejaculation,  and  the  orgasm.  In  impotence 
there  may  be  either  an  absence  or  weakness  of  any  one  of 
these  factors,  or  a  disturbance  in  the  relationship  among 
them.  We  may  therefore  systematically  discuss  the  symp- 
toms of  impotence  as  they  affect  the  factors  just  men- 
tioned : — 

(1)  Disturbance  of  the  Libido. — This  will  be  considered 
under  Psychic  Impotence. 

(2)  Disturbance  of  Erection  and  Ejaculation. — For  pur- 
poses of  treatment  it  will  be  necessary  to  consider  these 
two  factors  separately,  though  it  is  more  convenient  at 
present  to  consider  them  together.  The  symptoms  have 
partly  been  discussed  in  giving  the  pathology.  It  must  be 
remembered  that  the  patient  may  come  to  us  at  any  stage 
of  the  disease,  and  that,  for  a  proper  understanding  of  his 
condition,  we  must  go  into  his  past  sexual  history  most 
minutely  in  order  to  appreciate  the  proper  sequence  of 
events. 

In  the  classic  type,  as  illustrated  by  the  impotence  of 
withdrawal,  the  patient  first  notices  that  the  time  consumed 
in  coitus  is  not  as  long  as  it  previously  was.  His  erections 
are  perfectly  strong,  he  can  enter  the  vagina,   the  penis 


Impotence  in  the  Male.  81 

by  proper  interrogations,  get  a  complete  history  from  the 
patient,  depending  upon  what  stage  he  is  'in.  It  must  also 
be  remembered  that  the  first  symptoms  may  come  on  some 
time  after  withdrawal  has  been  stopped,  and  while  the 
patient  is  indulging  in  natural  coitus.  He  may  not  con- 
sider withdrawal  as  an  etiological  factor,  and  will  not 
mention  it,  or  even  deny  it,  unless  properly  questioned  in 
this  regard.  He  may  even  tell  you  that  previously,  while 
indulging  in  withdrawal,  his  coitus  was  better  than  at  pres- 
ent. The  reason  for  all  this  is  easy  to  understand  from  a 
consideration  of  the  pathology.  It  takes  some  time  for  the 
centers  to  become  exhausted,  and  every  act  of  coitus,  even 
natural  coitus,  aids  in  the  exhaustion  process,  once  the 
pathological  conditions  previously  mentioned  are  forming. 
So  that,  while  he  was  practising  withdrawal,  the  process 
had  not  yet  reached  the  final  stage.  As  long  as  he  remains 
untreated,  especially  while  irritating  the  parts  by  even 
natural  coitus,  the  pathological  processes  will  progress  to 
complete  exhaustion  and  impotence. 

It  has  been  customary  to  classify  functional  impotence 
as  either  paralytic  on  the  one  hand,  or  due  to  irritable 
weakness  on  the  other.  The  general  idea  seems  to  prevail 
that  they  are  separate  and  distinct  conditions,  and  repre- 
sent a  directly  opposite  condition  of  affairs.  My  experi- 
ence, however,  in  carefully  investigating  the  sequence  of 
events,  as  well  as  a  consideration  of  the  pathology  of  im- 
potence, has  long  ago  convinced  me  that  this  classification 
is  improper,  and  that  the  two  conditions  are  but  different 
stages  of  the  same  disease.  If  we  carefully  question  patients 
who  are  suffering  from  so-called  paralytic  impotence,  we 


Impotence  in  the  Male.  83 

tiire  is  entirely  different  from  that  of  a  man  with  feeble, 
rapid  ejaculation,  diminished  libido,  and  lack  of  satisfac- 
tion from  the  act.  In  this  case  there  is  intense  satisfaction 
from  the  coital  act.  Many  men  get  into  this  condition 
every  time  they  have  coitus  with  a  new  acquaintance. 

(3)  Disturbance  in  the  Orgasm. — The  exact  seat  of  the 
orgasm  is  not  known,  but,  for  various  physiological  rea- 
sons, it  is  believed  to  be  due  to  the  squeezing  of  the  fluid 
through  the  ejaculatory  ducts  into  the  posterior  urethra, 
through  muscular  action.  In  rapid  ejaculation  the  orgasm 
is  either  diminished  or  may  be  entirely  absent,  for  the  fol- 
lowing reason :  When  the  erection  center  sends  its  impulses 
too  rapidly  to  the  ejaculation  centers,  the  impulses  which 
are  sent  out  by  the  ejaculation  centers  are  also  weaker  than 
normal.  Therefore,  the  squeezing  out  of  the  fluid  through 
the  ejaculatory  ducts  becomes  less  intense  and  the  orgasm 
is  either  diminished  or  absent.  The  patient  obtains  no 
pleasure  from  coitus,  and  his  partner  also  suffers  on  ac- 
count of  the  too  short  time  of  friction  for  her  to  get  her 
orgasm.  It  is  very  often  that  this  lack  of  experiencing  the 
orgasm  is  the  chief  reason  why  the  patient  seeks  medical 
advice. 

Besides  the  symptoms  mentioned  above,  there  is  an 
important  group  of  cases  whose  symptoms  cannot  consis- 
tently be  classified  with  any  of  the  preceding  groups — cases 
where  there  is  an  entire  diminution  of  the  whole  process 
of  coitus.  To  this  class  belong  men  who  are  otherwise 
healthy,  never  suffer  from  neurasthenia,  but  in  whom  the 
sexual  functions  appear  very  late,  and  last  only  a  short 
time.    They  rarely  masturbate,  rarely  have  pollutions,  have 


84  Disorders  of  the  Sexual  Function. 


very  slight  libido,  and  easily  remain  continent.  They 
sometimes  marry  for  economic  or  other  reasons,  and  are 
impotent,  but  do  not  worry  very  much  about  their  condi- 
tion. These  men  would  never  seek  a  physician,  were  it  not 
that  they  are  driven  there  by  their  wives. 

I  cannot  emphasize  too  strongly  the  necessity  of  recog- 
nizing the  etiological  basis  of  this  condition.     There  is  a 
congenital  lack  of  sexual  desire  and  power,  which  is  the 
cause  of  the  easy  continence  and  the  impotence  in  these 
cases.    It  must  be  recognized  that  these  cases  are  horn  and 
not  made,  and  that  the  continence  is  due  to  the  same  lack 
of  sexual  vigor  as  the  impotency.     I  emphasize  this  fact, 
because  some  authorities,  reasoning  entirely  from  the  pre- 
vious history,  but  in  a  superficial  manner,   desire  us  to 
believe  that  the  long  period  of  continence  is  the  cause  of 
the  impotency.     I  believe  with  Sturgis,^2o  ^nd  many  other 
prominent  authorities  to  be  mentioned  later,   that  conti- 
nence is  never  a  cause  of  impotence.  By  continence,  however, 
I  mean  not  only  abstinence  from  sexual  coitus,  but  also 
abstinence  from  any  of  the  factors  which  arouse  the  sexual 
passion    (spooning,    dalliance,    caressing,    etc).      Absolute 
abstinence  from  all  such  factors  is  perhaps  an  impossibility, 
especially  in  large  cities,  which  abound  in  erotic  literature, 
erotic  shows  and  moving  pictures,  etc. ;  but  even  in  these 
cases  of  relative  abstinence,  impotence  never  occurs.     It  is 
only  in  those  cases  heretofore  described  (page  75)  where, 
on  account  of  long  engagements,  a  man  will  fondle  a  girl 
for  hours,  and  keep  this  up  every  night  for  months  at  a 
time,  that  temporary  impotence  might  result. 

Besides  the  local  symptoms  just  mentioned,  due  to  and 


Impotence  in  the  Male.  85 


part  of  the  impotence  itself,  there  is  a  series  of  local  symp- 
toms which  are  generally  mentioned  in  connection  with 
impotence,  but  which  have  really  nothing  to  do  with  it.  In 
most  of  the  cases  the  same  pathological  condition  in  the 
posterior  urethra,  the  prostate  and  seminal  vesicles,  which 
is  responsible  for  the  impotence,  is  also  responsible  for  the 
other  symptom.s.  It  is  just  as  logical  to  consider  the  lan- 
cinating pains  of  locomotor  ataxia  to  be  due  to  the  impotence 
which  is  also  present  in  locomotor  ataxia,  as  to  consider 
the  symptoms  about  to  be  described  as  symptoms  of  im- 
potence. In  both  cases,  both  are  simply  due  to  the  same 
underlying  cause. 

But,  while  appreciating  that  such  symptoms  are  not 
symptoms  of,  but  only  symptoms  often  accompanying  im- 
potence, it  is  well  that  they  should  be  mentioned  here,  and 
for  the  following  reasons :  After  all,  we  are  called  upon 
to  treat  the  patient  rather  than  the  disease.  Very  often 
the  patients  complain  much  more  about  these  accompanying 
symptoms  than  of  the  impotence.  Very  often,  also,  these 
accompanying  symptoms  precede  the  complete  exhaustion 
of  the  sexual  centers  for  a  long  time,  and  by  bearing  these 
facts  in  mind,  and  going  into  the  history  in  detail,  we  may 
sometimes  arrive  at  a  diagnosis  of  incipient  impotence,  and 
be  able  to  treat  the  same,  before  the  patient  has  really  appre- 
ciated the  gravity  of  his  condition.  Sometimes,  too,  these 
accompanying  symptoms  give  us  a  clew  to  the  pathological 
processes  at  work  which  not  only  cause  them,  but  which 
also  cause  the  impotence. 

Prominent  among  these  symptoms  may  be  mentioned 
frequency  of  urination  and  also  burning  on  urination,  as 


86  Disorders  of  the  Sexual  Function. 

well  as  pain,  mostly  at  the  end  of  urination.  Vesical  tenes- 
mus, incontinence  of  urine  as  well  as  difficulty  in  starting 
the  stream  of  urine,  and  dribbling  after  urination  are  also 
occasionally  met  with.  All  these  symptoms  are  due  to  the 
congested  and  irritated  condition  of  the  mucous  membrane 
of  the  posterior  urethra,  as  well  as  to  the  general  hyperemia 
of  all  the  pelvic  organs  which  is  found  after  a  long  period 
of  withdrawal  or  masturbation.  Pollutions,  either  noctur- 
nal or  diurnal,  as  well  as  defecation  and  urination  sper- 
matorrhea are  very  often  accompanying  symptoms  of  impo- 
tence, but  as  these  will  be  discussed  in  a  separate  chapter, 
no  further  mention  will  be  made  of  them  here. 

General  Sjmiptoms. — There  is  a  long  train  of  symptoms, 
too  numerous  for  description,  which  is  common  to  all  forms 
of  impotence  from  whatever  cause,  and  which  may  be  de- 
scribed under  the  general  term  of  sexual  neurasthenia.  Of 
this  character  are  pains  in  the  legs,  pains  over  the  eyes, — 
in  fact,  pains  in  any  and  every  portion  of  the  body.  Gen- 
eral weakness,  headache,  vertigo,  and  almost  any  kind  of 
or  combination  of  symptoms  is  met  with.  As  a  practical 
point  in  interpreting  these  symptoms,  care  must  be  taken 
not  to  blame  everything  on  the  sexual  neurasthenia,  but  to 
look  out  for  possible  errors  in  refraction,  or  errors  in 
digestion,  etc.,  as  their  cause. 

Besides  the  above  constitutional  symptoms,  there  is 
another  long  list  of  psychic  symptoms  which  has  been  very 
graphically  and  artistically  described  by  German  and  French 
authors.  I  will  not  attempt  to  give  here  a  graphic  descrip- 
tion of  the  miseries  and  psychic  emotions  of  the  impotent 
man,  but  will  simply  state  that  this  condition  is  at  times 


'P- 


^ 


Impotence  in  the  Male.  87 

the  cause  of  the  most  extreme  unhappiness,  and  not  infre- 
quently leads  to  suicide.  In  fact,  it  has  been  pointed  out 
by  those  who  have  investigated  the  subject,  that  not  a  few 
of  the  mysterious  suicides,  committed  by  apparently  happy 
and  contented  men  shortly  after  marriage,  w^ere  due  to 
their  discovering  that  they  w^ere  impotent. 

Diagnosis. — For  a  proper  diagnosis  of  functional  im- 
potence, it  is  necessary  to  take  the  entire  sexual  history  of 
the  patient  into  consideration.  It  is  not  sufficient  to  say  that 
the  patient  is  impotent;  he  knows  that  himself;  but  we 
must  diagnose  whether  it  is  the  erection  center  that  is  at 
fault,  or  the  ejaculation  center,  the  libido  or  a  combination 
of  all  of  them.  It  may  even,  at  times,  be  necessary  to 
interview  or  even  examine  the  wife.  This  is  especially 
important  in  the  newly  married.  In  one  case  that  came 
under  my  observation,  where  a  patient  had  been  under 
treatment  by  several  other  physicians  for  som.e  time  for 
impotence,  an  examination  of  the  wife  by  me  revealed  the 
fact  that  she  was  suffering  from  vaginismus,  for  which 
reason  the  husband  could  not  enter,  in  spite  of  fairly  strong 
erections.  Sometimes  other  malformations  about  the  female 
genitals  prevent  the  penis  from  entering,  until  the  unfor- 
tunate man  finally  becomes  discouraged  and  may  be  ren- 
dered temporarily  impotent  from  his  ineffectual  efforts. 

In  every  case  of  impotence,  we  should  examine  for 
locomotor  ataxia  or  other  nervous  condition  which  may 
cause  it. 

Prognosis. — The  prognosis  varies  considerably  in  the 
different  conditions.  It  is  generally  good  in  men  below  45 
who  have  been  able  to  perform  normal  coitus  before  their 


Disorders  of  the  Sexual  Function. 


present  impotency.  It  is  very  poor  in  cases  of  congenital 
lack  of  sexual  desire  and  vigor.  Wherever  a  man  has 
always  been  sexually  weak  from  the  very  commencement 
of  his  sexual  life,  and  has  superimposed  upon  this  congen- 
ital weakness  the  evil  influences  of  withdrawal  or  excessive 
masturbation,  the  prognosis  is  unfavorable.  It  is  also  not 
good  in  men  past  50,  or  in  men  with  a  neurasthenic  history 
to  which  the  evils  of  sexual  neurasthenia  have  been  added. 
The  prognosis  is  very  good  in  those  acute  forms  of  impo- 
tence due  to  overindulgence  in  coitus,  as  well  as  in  impo- 
tence from  ungratified  sexual  passion,  and  in  the  ordinary 
cases  of  impotence  from  v\^ithdrawal  or  excessive  mastur- 
bation in  which  there  is  no  underlying  condition  of  general 
neurasthenia.  The  prognosis  is  naturally  poor  in  the  con- 
firmed sexual  invert. 

Treatment. — In  order  to  properly  treat  the  condition 
under  consideration,  we  must  have  a  clear  conception  of 
the  pathological  state  of  affairs  and  the  causes  which  pro- 
duced them.  What  then  is  the  condition  of  affairs  in  the 
ordinary  case  of  functional  impotence?  There  are  hyper- 
irritated  or  exhausted  sexual  centers  depending  upon  the 
stage  of  the  disease,  and  a  chronically  inflamed  posterior 
urethra  with  congested  or  inflamed  seminal  vesicles  and 
prostate.  The  first  indication  is  absolute  sexual  rest  in 
order  to  give  the  exhausted  centers  time  to  recuperate,  and 
to  remove  every  cause  of  irritation,  which  includes  the  treat- 
ment of  the  diseased  posterior  urethra  and  prostate  and 
seminal  vesicles,  for,  as  has  been  shown  heretofore,  these 
diseased  organs  are  constantly  bombarding  the  sexual  cen- 
ters with  impulses,  even  in  the  absence  of  sexual  intercourse. 


'\S^v\AiM^'^ 


'r^^' 


Impotence  in  the  Male. 


89 


The  first  indication  is  met  by  not  only  abstaining  from 
coitus,  but  from  every  act  which  might  excite  the  sexual 
passion.     The  husband  should  not  sleep  in  the  same  room 
with  his  wife  if  possible,  certainly  not  in  the  same  bed.    He 
should  especially  be  cautioned  against  spooning,  for,  if  not 
told,  some  men  have  the  impression  that  they  may  indulge 
in  any  sort  of  sexual  play,   as  long  as  they  omit  actual 
coitus.     The  length  of  time  he  should  abstain  from  coitus 
varies  in  different  cases.     As  a  general  rule  it  may  be  said 
that  young  and  vigorous  men  should  be  kept  continent  for 
from  three  to  six  months,  while  men  past  45   should  be 
allowed  coitus  much  sooner,  for  fear. of  a  complete  dying 
out  of  the  sexual  impulse. 

Besides  the  abstinence  from  coitus,  the  patient  should 
also  abstain  from  all  alcoholics,  as  well  as  from  tea,  coffee, 
eggs  and  oysters,  for  all  these  stimulate  the  sexual  apparatus 
and  centers. 

At  this  time  nothing  is  so  useful  as  the  internal  admin- 
istration of  the  bromides  in  large  doses.  At  least  15  grains 
should  be  given  three  times  a  day  well  diluted  after  meals. 
The  object  of  this  is  to  quiet  the  irritated  centers,  and  at 
the  same  time  to  remove  all  sexual  desire  for  the  time 
being,  This  should  be  given  even  in  the  paralytic  stage 
of  the  disease,  and  not  reserved  for  the  cases  of  irritable 
weakness  only.  The  large  doses  of  the  bromides  should 
be  kept  up  for  at  least  two  months  in  young  persons  and 
for  one  month  in  older  patients,  and  then  gradually  re- 
duced. It  has  been  said  that  the  administration  of  bro- 
mides may  lead  to  impotence.  Possibly  the  prolonged 
administration  for  years  which  may  be  necessary  in  epilepsy 


90  Disorders  of  the  Sexual  Function. 


or  other  chronic  nervous  affections  may  have  this  resuh, 
but  certainly  for  the  Hmited  time  given  above  no  such 
result  can  occur.  The  patient  should  be  fully  informed  of 
the  object  of  the  treatment,  or  else  he  is  apt  to  be  dis- 
couraged and  tell  you  that  his  condition  is  getting  worse 
instead  of  better.  He  will  inform  you  that  before  he  started 
treatment  he  had  some  sexual  desire,  while  now  he  has 
none.  As  a  matter  of  fact,  this  is  just  what  is  wanted, 
and  is  the  main  object  of  the  administration  of  the  bro- 
mides. The  patient  should  therefore  be  informed  of  these 
facts  at  the  very  start. 

At  the  very  commencement  of  treatment,  in  fact  at  the 
first  examination,  we  should  inform  ourselves  of  the  con- 
dition of  the  prostate,  seminal  vesicles  and  urethra,  espe- 
cially the  posterior  urethra.  For  this  purpose  a  routine 
genitourinary  examination  should  be  made,  including  a 
search  for  stricture  and  an  endoscopic  examination  of  the 
entire  urethra.  A  routine  urine  examination  should  be  also 
made  to  rule  out  diabetes  as  a  possible  etiological  factor. 
In  many  of  these  cases  we  will  find  areas  of  congestion  or 
other  pathological  conditions  in  the  region  of  the  verumon- 
tanum.  The  prostate  and  seminal  vesicles  will  also  often 
be  found  enlarged  and  sensitive. 

For  the  treatment  of  these  pathological  conditions  in  the 
posterior  urethra,  nothing  succeeds  so  well  as  the  instil- 
lations of  weak  silver-nitrate  solutions  through  the  Bangs 
sound  syringe,  just  as  in  cases  of  masturbation.  The  instil- 
lations are  given  every  five  days,  starting  'with  a  i  :  3000 
solution  and  increasing  to  >4%.  The  size  of  the  sound  is 
also  increased  till  the  largest  possible  can  be  taken.    Should 


Impotence  in  the  Male.  91 


there  occur,  at  any  time,  too  much  irritation  from  the  instil- 
lations, as  evidenced  by  urethral  discharge  or  very  intense 
burning,    the    strength   of   the    silver   solution   should    be 
reduced.     Of  course  if  the  endoscope  reveals  any  gross 
pathological   condition  in  the  posterior  urethra,    such   as 
cysts,  vegetations,   or  similar  conditions,   these  should  be 
removed  either  by  puncturing  or  other  intra-urethral  oper- 
ation, which  is  very  feasible  through  the  modern  posterior 
urethroscope.     After  the  very  acute  condition  of  conges- 
tion has  been  removed  by  the  above  instillations,  a  few 
direct  applications  of  very  strong  silver  solution  (lo^o  to 
20%)  can  be  made  advantageously  to  the  diseased  areas. 
I  have  often  been  asked  how  the  application  of  silver 
nitrate  to  the  verumontanum  could  possibly  cure  impotence. 
To  this  I  must  answer  that  the  application  of  silver  nitrate 
to  the  normal  verumontanum  can  only  do  harm,  but  he  who 
has  looked  through  the  modern  endoscope  and  has  seen  the 
pathological  conditions  present  can  readily  understand  how 
the  removal  of  these  conditions  can  have  a  beneficial  effect 
upon  the  coital  act.     I  desire  especially  to  emphasize  the 
fact  that  the  treatment  is  not  psychic,  although  the  intro- 
duction of  the  lighted  endoscope  cannot  help  having  a  psychic 
effect  on  the  patient.     The  treatment  and  the  good  results 
of  the  treatment  are  due  solely  to  the  removal  of  the  patho- 
logical conditions  present.     The  indiscriminate  application 
of  strong  caustics  to  the  verumontanum,  practised  years 
ago  as  a  cure  for  impotence,  has  deserved  the  severe  cen- 
sure which  it  has  received,  but  the  rational  treatment  of 
the  diseased  areas  which  can  be  so  distinctly  seen  through 
modern  instruments  is  of  distinct  benefit  to  the  patient. 


92  Disorders  of  the  Sexual  Function. 

One  must  have  considerable  experience  in  posterior 
endoscopy,  however,  before  he  can  recognize  what  is  patho- 
logical and  what  is  normal.  The  verumontanum,  like  the 
trigone  of  the  bladder,  is  normally  redder  than  the  sur- 
rounding parts,  and  the  inexperienced  observer  is  likely  to 
consider  the  normal  verumontanum  to  be  congested  or 
inflamed.  The  same  holds  good  also  concerning  its  size. 
We  must  remember  that  the  normal  verumontanum  varies 
greatly  in  size  and  shape  in  different  individuals.  In  the 
colored  race,  for  instance,  where  all  sexual  organs  are 
markedly  developed,  I  have  noticed  that  the  verumontanum 
is  much  larger  than  in  white  persons.  I  have  evolved  the 
following  rule  as  a  guide:  we  must  not  be  guided  by  the 
absolute  size  of  the  verumontanum,  but  by  its  size  in  rela- 
tion to  the  posterior  urethra  in  which  it  is  found.  In  other 
words,  a  verumontanum,  which  almost  completely  fills  the 
prostatic  urethra,  showing  little  if  any  signs  of  lateral  si- 
nuses, that  is  to  say,  if  it  almost  touches  -the  walls  of  the 
urethra  on  either  side,  is  to  be  considered  considerably 
enlarged.  One  can  easily  appreciate  how  such  a  verumon- 
tanum must  keep  on  tickling  the  walls  of  the  prostatic 
urethra  even  in  the  absence  of  coitus,  and  also  how  irritat- 
ing it  must  be  when  rendered  more  congested  during  the 
coital  act. 

It  must  be  remembered  that  the  posterior  endoscope  only 
shows  the  pathological  condition  of  the  posterior  urethra, 
and  that  similar  pathological  states  are  found  in  other 
conditions  such  as  masturbation,  satyriasis,  etc.  In  other 
words,  one  cannot  make  a  diagnosis  of  impotence  by  merely 
looking  through  the  endoscope. 


Impotence  in  the  Male. 


93 


~  -   Lateral   sulcus. 
<_  _  ~.  Urethral   wall. 


'— *  Verumontanum. 
1.  Normal  verumontanum. 


-5^  —  —  Lateral  sulcus. 
—  Urethral   wall. 


•~  ""  Verumontanum. 
2.  Moderately  enlarged  verumontanum. 


—  —  Lateral   sulcus. 
—  —  —  Urethral   wall. 


—  —  Lateral  sulcus. 

—  —  Urethral   wall. 


—  —  —  Verumontanum.  '  - —  Veruiaontanum. 

3.  Very   enlarged   verumontanum.        4.    Atrophic   verumontanum. 


Diagrammatic  pictures  of  normal  and  diseased  verumontanum. 


94  Disorders  of  the  Sexual  Function. 


At  the  same  time  that  we  are  treating  the  pathological 
conditions  in  the  posterior  urethra,  we  also  treat  the  en- 
larged, congested  and  sensitive  prostate,  and  seminal  ves- 
icles, by  gentle  massage  every  five  days.    Gentle  massage  is 
an  art  which  requires  much  practice  to  obtain.    It  is  a  pity 
that  any  manipulation  of  the  prostate  is  designated  by  the 
term  massage.    This  is  really  a  mistake.    When  we  manipu- 
late the  prostate  in  cases  of  gonorrhea  in  order  to  get  out 
its  secretions  for  diagnostic  or  therapeutic  purposes,  we  are 
justified  in  using  quite  hard  pressure,  but  this  process  ought 
really  to  be  called  expression  instead  of  massage.     Such 
procedure  is  entirely  different  from  what  the  one  now  under 
consideration  should  be.     It  must  be  remembered  that  the 
object  of  the  manipulation  is  not  to  squeeze  out  every  drop 
of  secretion  from  the  prostate,  but  to  relieve  the  congestion 
and  to  help  the  exhausted  muscles  of  the  prostate  to  regain 
their  tone.     In  other  words,  massage  in  the  same  sense  in 
which  that  term  is  used  when  applied  to  other  portions  of 
the  body.     Using  powerful  pressure  on  the  inflamed  and 
sensitive  prostate  is  no  more  massage  of  that  organ  than 
punching  a  man  in  the  belly  would  be  considered  massage 
of  the  abdomen. 

This  combined  treatment— to  wit,  abstinence,  restricted 
diet,  bromides,  intra-urethral  treatment,  and  prostatic  mas- 
sage—should be  kept  up  for  several  months,  depending  upon 
the  age  of  the  patient,  the  stage  of  the  disease,  and  also 
the  reaction  to  the  treatment.  During  this  time  his  general 
health  should  receive  the  closest  attention.  A  liberal  and 
easily  digested  diet,  largely  made  up  of  cream  and  other 
fats,  should  be  ordered.     Constipation  must  be  relieved,  as 


Impotence  in  the  Male. 


it  tends  toward  interference  with  the  return  pelvic  circula- 
tion and  thus  makes  for  local  congestion.  Tonics  and  out- 
door exercises  should  be  ordered  where  feasible.  A  very 
useful  adjuvant  is  cold  baths  or  cold  spinal  douches.  These 
are  to  be  taken  only  in  the  morning  and  never  at  night. 
Hot  baths  are  positively  injurious. 

If  at  any  time  frequent  pollutions  occur,  we  must  at 
once  suspend  massage  of  the  prostate ;  otherwise  this  pro- 
cedure is  to  be  kept  up  at  increasing  intervals,  until  that 
organ  is  no  more  congested  and  its  sensitiveness  is  gone. 
One  must  have  some  experience  however  in  deciding  these 
points,  as  we  can  always  squeeze  hard  enough,  even  on  a 
normal  prostate,  to  cause  pain. 

When  we  have  decided  that  the  sexual  centers  have 
fully  recuperated,  and  observe  that  the  posterior  urethra  as 
well  as  the  adnexa  are  normal,  we  stop  the  bromides  and 
turn  to  sexual  stimulants.     I  have  tried  most  of  the  drugs 
recommended,  but  have  gradually  narrowed  down  my  med- 
ical armamentarium  to  two  drugs,  namely,  strychnine  and 
yohimbin.     Strychnine  nitrate  is  to  be  preferred,  although 
where  this  is  not  obtainable  the  sulphate  acts  almost  as 
well.     I  have  become  convinced  that  those  who  have  not 
obtained  good  results  from  this  drug  have  not  administered 
it  in  the  proper  way  or  dosage.     Many  years  ago,   that 
great  clinical  observer,  Abraham  Jacobi,  stated  that  the  dose 
of  this  drug  for  children  is  generally  put  down  as  much 
too  small,  and  I  have  come  to  the  same  conclusion  in  regard 
to  its  use  in  adults.     Where  coitus  is  indulged  in  during 
the  night,  I  order  V20  grain  of  either  strychnine  nitrate 
or  sulphate  to  be  taken  at   5   p.m.,   7   p.m.,   9   p.m.,   and 


/5     . 


96  Disorders  of  the  Sexual  Function. 

II  P.M.  Although  the  patient  thus  gets  gr.  V/g  in  six 
hours,  I  have  never  noticed  any  bad  effects  from  it.  At 
first  there  may  be  some  headache,  but  this  soon  passes  off, 
and  the  patients  frequently  tell  me  that  they  sleep  much 
better  than  before.  It  should  be  stated  here,  that  strych- 
nine has  no  direct  effect  upon  the  sexual  desire.  All  it  does 
is  to  make  the  penis  stiff  so  that  it  can  enter  the  vagina 
and  remain  in  the  erect  condition  during  coitus.  Frequently 
the  penis  even  remains  stiff  after  coitus  is  completed,  and 
comes  out  in  an  erect  condition  also.  Yohimbin  acts  very 
well  within  certain  limitations.  It  must  not  be  given  so 
long  as  premature  ejaculations  continue,  or  where  frequent 
pollutions  complicate  the  impotence.  It  is  not  to  be  given 
continuously,  but  should  be  given  for  from  one  week  to 
two  weeks  at  the  utmost,  in  doses  of  i  tablet  three  times 
a  day.  Its  chief  indication  is  after  a  long  period  of  sexual 
continence,  and  when  the  erection  center  has  been  completely 
rested.  The  rested  center  will  now  react  splendidly  to  this 
drug  and  the  first  and  much  feared  coitus  will  be  success- 
ful. Some  authors  recommend  it  to  be  given  subcutane- 
ously.  Lissman'''^  reported  excellent  results  with  the  epi- 
dural injection  of  yohimbin  solution,  even  in  cases  where 
the  tablets  had  failed.  I  have  had  no  experience  however 
with  either  the  subcutaneous  or  epidural  method  of  admin- 
istering yohimbin;  but,  given  in  tablet  form  at  the  right 
time  and  within  the  limitations  above  mentioned,  it  has 
generally  worked  very  well. 

I  desire  to  record  here  some  experiments  I  have  made 
with  tincture  of  cantharides  in  cases  of  impotence.  It  Is 
well  known  that  this  drug,  if  taken  in  large  enough  doses 


Impotence  in  the  Male.  97 


may  cause  priapism,  for  which  reason  it  had  often  been 
given  for  the  purpose  of  bringing  on  erection.  The  drug 
is,  however,  a  very  powerful  irritant  to  all  mucous  mem- 
branes. If  taken  internally,  in  sufficiently  large  doses,  it 
causes  a  gastroenteritis,  a  nephritis,  and  an  intense  inflam- 
mation of  the  mucous  membrane  of  the  bladder  and  ure- 
thra. It  is  by  causing  this  inflammation  of  the  genitourinary 
mucous  membrane  that  the  erections  are  brought  on,  and 
death  has  at  times  resulted  from  its  use  for  this  purpo'se. 

Several  years  ago  it  occurred  to  me  that  if  cantharides 
has  this  effect,  what  is  the  necessity  of  administering  it  in 
poisonous  doses,  thereby  causing  gastroenteritis,  nephritis, 
and  cystitis  in  order  to  bring  a  sufficient  quantity  of  the 
drug  into  contact  with  the  mucous  membrane  of  the  urethra 
in  order  to  cause  erection,  when  by  means  of  the  endoscope 
or  with  the  syringe  the  drug  may  be  applied  directly  to  the 
urethral  mucous  membrane?     Accordingly,   I   started  my 
experiments  with  very  weak  solutions,  and  gradually  in- 
creased the  strength,  until  it  became  evident  that  about  a 
50%  or  at  most  a  75%  solution  of  the  tincture  of  canthar- 
ides was  as  strong  a  dosage  as  could  be  given  by  instillation. 
I  even  made  direct  appHcation  of  the  pure  tincture  of  can- 
tharides to  the  verumontanum,  and,   while  irritation  was 
produced,  as  shown  by  a  sense  of  burning  and  frequency 
of  unnation,  there  was  never  the  slightest  indication  of 
erection.     No  harm   resulted   to  the  patients   from   these 
experiments.     Cantharides  given  internally  may  possibly  be 
excreted  with  the  urine  in  some  peculiar  chemical  combina- 
tion, or  may  form  some  chemical  combination  in  the  blood 
which  is  excreted  in  such  a  form  as  to  irritate  the  erection 


98  Disorders  of  the  Sexual  Function. 


center  and  thus  cause  the  priapism.  A  search  through  med- 
ical literature  for  some  explanation  as  to  how  cantharides 
is  excreted  threw  no  light  upon  the  subject.  To  those  who 
have  access  to  physiological  laboratories,  it  might  be  inter- 
esting to  work  out  this  problem,  or  the  experiment  may 
be  tried  by  giving  rabbits  or  other  animals  poisonous  doses 
of  cantharides,  and  then  collecting  their  urine,  to  ascertain 
what  effect  this  urine  may  have  if  applied  directly  to  the 
posterior  urethra. 

The  treatment  of  those  cases  in  which  there  is  a  con- 
genital lack  of  sexual  vigor  is  very  unsatisfactory,  and  all 
we  can  do  is  to  conserve  whatever  power  they  have,  by 
warning  them  against  excessive  coitus  and  withdrawal. 

It  is  very  important  to  impress  upon  patients  that  the 
best  we  can  do  is  to  get  their  organs  into  normal  condition, 
but  that  we  cannot  so  educate  their  organs  that  they  can 
abuse  them  without  coming  to  grief.  In  other  words,  if 
we  have  succeeded  in  curing  the  impotence  which  was 
caused  by  coitus  interruptus,  the  patient  must  be  made  to 
understand  that  if  he  resumes  the  practice  he  will  surely 
relapse,  and  the  same  is  true  of  the  other  etiological  factors. 


.M 


CHAPTER  VI. 
III.  PSYCHIC  IMPOTENCE. 

InhSfef 'hk'h  ^*'n°^-  P^^hology.  Symptoms.  Misdirected  libido. 
Inhibited  hbido.  Diagnosis.  Prognosis.  Treatment.  Impotence  in 
the    femal.      Definition.      Etiology    and    pathology.      Obstruc  ive    im- 

TreTtm;nt.        "'"    ^"^°*^""-      '^"^^*°"^^-      ^^^^---      ^-^o^- 

Definition.— Psychic  impotence  is  that  condition  in  which 
the  impotence  is  caused  by  inhibitory  influences  from  the 
higher  centers.  While  in  organic  impotence  the  trouble  is 
with  the  end-organs,  and  in  functional  impotence  it  is  gen- 
erally the  sexual  centers  which  are  at  fault,  in  psychic  im- 
potence there  are  healthy  end-organs  and  healthy  centers 
but  the  actions  of  the  centers  are  interfered  with  by 
inhibitory  influences.     Groag^^  j^^^jy  ^^jj^  ^^^^^^.^^  ^^  ^^^ 

fact  that  the  term  has  been  very  unhappily  chosen,  inas- 
much as  some  of  the  other  forms  of  impotence  are  also 
partially  psychic,  and  he  therefore  suggests  the  term  "inhi- 
bition impotence"  instead. 

Etiology.  —Any  act  or  factor  which  can  influence  the 
imagination  may  be  the  cause  of  sexual  inhibition.  Among 
the  more  common  factors  may  be  mentioned  fear  of  vene- 
real disease,  fear  of  pregnancy,  fear  of  being  caught  in  the 
act,  fright,  disgust  of  the  partner,  fear  of  being  impotent 
on  account  of  youthful  masturbation,  etc.  Among  the 
unusual  causes  may  be  mentioned  joy,  as  in  a  case  reported 
by  Roubaud  where  a  man  became  impotent  on  hearing  that 
he  won  a  large  sum  of  money  in  the  lottery;  marital  indif- 

(99) 


100  Disorders  of  the  Sexual  Function.       

ierence,  as  in  a  case  mentioned  by  Sturgis^^^  in  which  the 
wife  considered  the  conjugal  act  to  be  vulgar  and  indecent, 
and  during  coitus  indulged  in  running  comments  upon  the 
performance;  superstition  is  reported  in  a  case  by  Ham- 
mond, where  a  man  believed  his  wife  had  given  him  a  certam 
glance  to  make  him  impotent  while  away  from  home;  the 
celebrated  case  mentioned  by  de  Caux,  in  which  a  mathema- 
tician was  always  diverted  from  coitus  by  a  certam  geo- 
metric problem  coming  up  at  the  psychic  moment. 

Pathology.— In  ordinary  coitus,  as  soon  as  the  libido  is 
aroused,  an  impulse  is  sent  from  the  cerebrum  (C,  Fig.  i, 
page  67)  to  the  erection  center  (R)  and  erection  occurs. 
In^the  condition  under  consideration  the  libido  is  normal, 
and  may  even  be  very  powerful,  but  inhibitory  impulses  are 
sent  from  other  cerebral  centers  to  C,  preventing  it  from 
sending  impulses  to  the  erection  center  (R).  In  those  cases 
where  erection  has  already  commenced,  the  inhibition  is 
transmitted  further  from  C  to  R,  thus  stopping  the  forming 

erection. 

Symptoms.— There  are  two  forms  of  psychic  impotence: 

(i)  misdirected  libido;  (2)  inhibited  libido. 

I.  Misdirected  Libido.— {a)  Sexual  perverts.  Normally 
the  libido  of  a  mature  man  is  directed  toward  a  female. 
If,  however,  the  libido  is  directed  toward  any  other  source, 
the  person  is  a  pervert.  Sometimes  such  men  marry  for 
social  or  economic  reasons,  but  the  presence  of  the  wife- 
does  not  excite  in  them  the  libido,  and  they  are  impotent. 
The  seat  of  the  trouble  is  probably  in  the  cerebrum  (C). 
(&)  Impotence  of  the  roue.  On  account  of  too  frequent 
coitus,  these  persons  find  no  longer  pleasure  in  normal 


M 


S^S^u 


ASL^'I 


•J» 


Impotence  in  the  Male.  loi 


coitus,  and  therefore  seek  for  stronger  and  stronger  methods 
of  excitement  in  order  to  cause  erection  (Moll's  excitement 
hunger).  According  to  our  diagrammatic  scheme,  the 
impulses  from  C  (cerebrum)  to  R  (erection  center)  are 
too  weak  during  normal  coitus  to  excite  R,  so  that  a 
strengthening  of  the  impulses,  through  the  addition  of  new 
psychic  excitements,  is  necessary. 

(c)  Relative  impotence.  Under  this  heading  may  be 
mentioned  those  cases  where  the  husband,  after  many  years 
of  married  life,  becomes  impotent  with  his  wife,  though 
perfectly  potent  with  other  women.  To  this  class  also 
belong  those  curious  cases,  where  men  are  potent  only  with 
certain  types  of  women,  either  blondes  or  brunettes  or  other 
physical  characteristics,  and  are  impotent  with  all  other 
types  of  women.  Also  those  cases  in  which  the  man  can 
only  indulge  in  coitus  if  the  woman  has  a  certain  kind  of 
dress  on,  or  her  hair  done  up  in  a  certain  way.  Groag^^ 
rightly  remarks  that  the  term  has  been  very  unhappily 
chosen,  as  the  two  previous  kinds  of  impotence  just  de- 
scribed are  also  cases  of  relative  impotence. 

The  three  forms  of  impotence  due  to  misdirected  libido 
just  mentioned  are  sometimes  classed  under  functional 
rather  than  psychic  impotence. 

2.  Inhibited  Libido. — The  symptoms  have  already  been 
partly  described  with  the  etiology.  The  person  has  normal 
or  even  intense  libido,  but  just  at  the  exciting  moment  • 
either  the  erection  fails  to  occur  or  if  it  has  started  it 
suddenly  ceases.  At  each  further  attempt  the  same  thing 
occurs,  and  may  even  be  worse.  The  same  train  of  neu- 
rasthenic symptoms  may  follow  this  condition,  as  has  been 


102  Disorders  of  the  Sexual  Function. 


mentioned  in  the  other  forms  of  impotence.  As  far  as  the 
patient  is  concerned,  he  is  just  as  unhappy  as  if  the  im- 
potence were  caused  by  the  most  pronounced  organic  or 
central  lesion. 

Diagnosis. — The  diagnosis  can  only  be  made  by  a  careful 
consideration  of  the  patient's  history,  together  with  a  most 
careful  genitourinary  examination,  as  well  as  a  general 
examination.  Cases  which  at  first  blush  seem  to  be  obvious 
cases  of  psychic  impotence  may,  on  careful  examination, 
turn  out  to  have  a  definite  organic  or  functional  etiology. 
The  most  important  points  in  the  diagnosis  are  the  presence 
of  normal  libido,  the  absence  of  organic  defects  or  diseases, 
the  absence  of  a  history  of  coitus  interruptus  or  other 
unnatural  sexual  excitation,  and  the  presence  of  a  definite 
psychic  history. 

Prognosis. — The  prognosis  is  generally  excellent. 
Treatment. — The  treatment  is  entirely  psychic,  but  this 
does  not  mean  that  the  patient  should  be  neglected.  It  is 
a  grave  mistake  to  tell  the  patient  there  is  nothing  the 
matter  with  him,  or  even  to  laugh  at  him.  For  this  reason 
as  well  as  for  proper  diagnosis  it  is  well  to  carefully  ex- 
amine him,  because  the  thoroughness  of  the  examination 
impresses  the  patient  and  helps  toward  the  cure.  Endo- 
scopic examination,  in  which  the  patient  sees  the  lighted 
instrument  enter  the  canal  and  appreciates  that  the  physi- 
cian can  see  everything  inside,  is  especially  impressive. 
Electricity  has  here  its  greatest  value.  It  is  this  form  of 
impotence  that  has  been  cured  by  anything  varying  from 
a  bread  pill  to  Christian  Science.  Hammond  has  been 
successful  by  giving  the  patient  some  indifferent  pills,  telling 


■•uJ^ 


K^f 


I 


I^mI 


Impotence  in  the  Female.  10( 


the  patient  that  he  may  sleep  with  his  wife,  but  under  no 
circumstances  indulge  in  coitus  until  all  the  pills  have  been 
taken.  Very  often  the  patient  breaks  the  rule  and  finds 
himself  potent.  It  may  be  necessary  to  instruct  the  wife 
and  have  her  assist  in  the  coital  act,  and  by  her  common 
sense  in  many  ways  also.  In  the  case  of  the  mathematician 
above  referred  to  his  wife  cured  him  by  making  him  par- 
tially intoxicated  before  coitus.  A  change  of  scene  or  even 
different  lodgings  has  resulted  in  a  cure. 

IMPOTENCE  IN  THE  FEMALE. 

Definition.— Impotence  in  the  female  may  be  defined  as 
that  condition  in  which  the  entrance  of  the  male  organ 
for  copulation  is  impossible. 

Etiology  and  Pathology.— We  may  recognize  two  forms 
of  impotence:  (i)  obstructive  and  (2)  non-obstructive  or 
neurotic. 

I.  Obstructive   Impotence.— R^rt   there   is    some   me- 
chanical obstruction  to  the  intromission  of  the  penis,  or  an 
absence  of  the  parts.     Passing  from  without  inward  there 
may  be  present  such  conditions  as  abnormality  of  the  hymen 
in  which  this  organ  is  of  excessive  strength  and  rigidity; 
also  imperforate  hymen;  adhesions  between  the  labia  majora 
or  labia  minora,— these  adhesions  may  either  be  congenital 
or  acquired ;  excessive  size  of  the  labia  majora,  as  in  ele-  . 
phantiasis;  new  growths  about  or  in  the  cellular  tissues  of 
the  external  genitals;  Hottentot  apron,  or  hypertrophy  of 
the  nymphs,  is  occasionally  met  with;  hypertrophy  of  the 
clitoris  has  also  been  found  to  attain  such  enormous  dimen- 


104  Disorders  of  the  Sexual  Function. 

sions  as  to  interfere  with  coitus;  absence  of  the  vagina, 
stricture  of  the  vagina,  either  acquired  or  congenital ;  irregu- 
lar ligamentous  bridges  sometimes  form  in  the  vagina  as 
the  result  of  tears  on  opposite  sides  of  the  vagina;  tumors 
of  the  vagina;  duplication  of  the  vagina;  extreme  narrow- 
ing of  the  vagina  sometimes  accompanies  marked  pelvic 
contraction.  In  rare  cases  the  vagina  may  be  occupied  by 
a  markedly  elongated  and  h3^pertrophied  cervix,  by  inver- 
sion or  prolapse  of  the  uterus,  by  uterine  polyp,  and  by 
cystocele  or  rectocele.  These  latter  deformities  must  be 
extreme  to  interfere  with  coitus,  as  I  have  seen  very  marked 
cases  of  all  these  latter  deformities  without  however  inter- 
fering with  coitus. 

2.  N on-obstructive  or  Neurotic  Impotence. — In  this 
class  of  cases  the  male  organ  can  enter  the  vagina,  but 
causes  such  extreme  pain  or  calls  forth  such  violent  spasms 
of  the  muscles  that  coitus  is  impossible.  Under  this  head- 
ing may  be  mentioned  vaginismus,  dyspareunia  and  all  the 
etiological  factors  which  are  mentioned  under  these  con- 
ditions (see  chapters  on  Vaginismus  and  Dyspareunia), 

Symptoms.  — The  only  symptom  is  the  inability  of  the 
male  organ  to  enter  the  female  genitals :  there  may  be  other 
symptoms  present  (see  Dyspareunia  and  Vaginismus),  but 
these  are  due  to  the  pathological  condition  and  not  to  the 
impotence.  As  a  general  thing,  impotence  in  the  female 
does  not  bring  with  it  the  long  train  of  neurotic  symptoms 
which  have  been  described  in  the  male. 

Diagnosis. — The  important  thing  is  to  diagnose  the  cause 
of  the  impotence. 

Prognosis   depends  upon  the  ability  to  remove  the  cause. 


^€07 


Pl 


"~¥^'W'~' 


Impotence  in  the  Female.  lo- 


Treatment.— The  treatment  of  the  obstructive  form  is 
mainly  surgical.  Even  complete  absence  of  the  vagina  has 
been  cured  by  forming  an  artificial  vagina  from  the  sur- 
rounding tissues,  with  the  help  of  skin-grafts.  For  the 
treatment  of  the  neurotic  forms  see  the  chapters  on  Dyspa- 
reunia  and  Vaginismus. 


CHAPTER  VII. 
POLLUTIONS  IN  THE  MALE. 

Definition  Authors  definition.  Diurnal  pollutions.  Nocturnal 
pollutions.  Defecation  spermatorrhea.  Urination  spermatorrhea. 
Urethrorrhea.  Prostatorrhea.  Confusion  in  terms  of  various  authors. 
Etiolocn-  Prostatic  massage  a  cause  of  pollutions.  Results  of  mastur- 
bation^a  cause.  Normal  pollutions.  Pathology.  Physiology  of  coitus. 
Local  pathology.  Pathology  of  defecation  spermatorrhea.  Opinions 
of  various  authors.  Author's  opinions.  Pathology  of  urethrorrhea. 
Symptoms.  Ouack  literature.  Pollution  dreams.  Practical  impor- 
tance of  pollution  dreams.  General  symptoms.  Diagnosis.  Prognosis. 
Prophylactic  treatment.  General  treatment.  Bromides.  Deep  instil- 
lations.    Psychrophore.     Pollutions  in  the  female. 

Definition.— Under  this  heading  I  include  any  involun- 
tary semen-like  discharge  coming  out  of  the  penis  and  not 
connected  with  coitus. 

I  have  purposely  made  this  definition  a  very  broad  one 
in  order  to  include  all  discharges  which  have  been  classified 
as  spermatorrhea,  involuntary  seminal  emissions,  prostator- 
rhea, defecation  spermatorrhea,  urination  spermatorrhea, 
and  iirethrorrhoea  ex  libidine  sexuale. 

I  have  done  this  in  order  to  simplify  the  subject,  which 
has  been  unnecessarily  complicated  by  distinctions  and  pa- 
thology which  do  not  exist,  except  in  the  case  of  urethror- 
rhea, which  is  distinct  from  any  of  the  other  conditions. 

Many  authors  make  a  distinction  between  spermatorrhea 
and  pollutions,  but,  from  both  a  clinical  and  pathological 
point  of  view,  this  is  erroneous,  and  unnecessarily  compli- 
cates the  subject.  It  may  be  interesting  to  examine  the 
discharge  for  spermatozoa,  but  no  deductions  can  be  made 
(106) 


Pollutions  in  the  Male.  107 

therefrom.  When  we  consider  that  (except  in  urethror- 
rhea)  the  discharge  comes  into  the  urethra  through  the 
ejaculatory  ducts,  and  that  the  seminal  vesicles  are  a  store- 
house for  the  spermatozoa  in  the  intervals  of  coitus,  we 
can  easily  understand  that  spermatozoa  may  be  found  in 
any  such  discharge.  Even  those  who  try  to  make  a  dis- 
tinction between  discharges  with,  and  those  without  sper- 
matozoa, make  the  significant  statement  that  many  exami- 
nations are  necessary,  and  that  the  absence  of  spermatozoa 
from  the  discharge  does  not  prove  that  the  condition  is  not 
spermatorrhea,  as  in  this  condition  spermatozoa  may  be 
absent  for  a  time.  They  further  admit  that  in  what  they 
distinguish  as  pollutions,  spermatozoa  may  also  be  present 
from  time  to  time. 

Pollutions  may  be  either  diurnal  or  nocturnal.  Pollu- 
tions which  accompany  defecation  are  called  ''defecation 
spermatorrhea,"  while  a  semen-like  discharge  coming  after 
urination  is  called  "urination  spermatorrhea."  The  term 
"wet  dreams"  is  often  applied  to  pollutions,  especially  by 
the  laity,  on  account  of  erotic  dreams  which  so  often  ac- 
company this  condition,  but  such  dreams  are  very  often 
absent.  Prostatorrhea  is  a  term  which  is  applied  to  a  dis- 
charge which  is  supposed  to  come  purely  from  the  prostate, 
but  without  any  inflammation  of  this  organ. 

When  we  consult  the  various  authorities  who  try  to 
make  a  distinction  between  the  various  conditions  above 
mentioned,  we  not  only  find  the  greatest  difficulties  in 
endeavoring  to  understand  the  points  in  differential  diag- 
nosis of  the  various  conditions  in  the  writings  of  any  one 
author,  but  also  the  greatest  confusion  among  the  various 


108  Disorders  of  the  Sexual  Function. 


authors  themselves.  Thus,  the  very  point  put  down  by  one 
authority  as  the  most  important  differential  diagnostic  point 
in  any  condition  is  mentioned  by  another  authority  as  the 
most  important  in  another  condition.  From  a  long  and 
careful  clinical  observation  of  these  conditions,  however, 
and  a  careful  study  of  their  pathology,  I  have  come  to  the 
conclusion  that  this  complication  of  terms  is  entirely  un- 
warranted, and,  from  the  standpoint  of  treatment,  entirely 

unnecessary. 

Urethrorrhcea  ex  libidine  sexuale,  on  the  other  hand, 
differs  from  the  above,  in  being  purely  a  secretion  of 
Cowper's  glands  and  those  of  the  urethral  follicles  and 
glands,  called  into  action  by  sexual  excitement  just  as  in 
normal  coitus,  but  without  the  coitus  being  indulged  in. 

Etiology.  —Any  factor  which  either  causes  a  distention 
of  the  seminal  vesicles  or  irritates  the  prostatic  urethra  or 
the  glands  of  Cowper  or  the  urethral  glands  may  cause 
pollutions.  Among  such  factors  may  be  mentioned  ungrati- 
fled  sexual  excitement,  coitus  interruptus,  the  results  of 
masturbation,  excessive  horseback  riding,  excessive  bicycle 
riding,  or  inflammations  of  the  posterior  urethra.  Among 
the  rarer  causes  may  be  mentioned  rectal  worms  and  epi- 
lepsy. Hamilton  has  called  attention  to  the  fact  that  in 
rare  cases  a  pollution  may  also  be  the  expression  of  an 
epileptic  seizure. 

A  very  frequent  cause  of  pollutions,  and  one  to  which 
little,  if  any,  attention  has  been  paid  as  an  etiological  factor, 
is  massage  of  the  prostate  with  stripping  of  the  seminal 
vesicles.  I  have  very  often  found  pollutions  to  appear  after 
this  procedure,  whether  done  for  gonorrhea  (expression  for 


Pollutions  in  the  Male.  109 

diagnostic  or  therapeutic  purposes)  or  whether  done  as  part 
of  the  routine  treatment  in  masturbation  or  impotence  or 
other  forms  of  sexual  neuroses. 

Attention  should  be  called  to  the  fact  that  in  giving 
the  etiology  I  have  mentioned  the  results  of  masturbation 
and  not  masturbation  itself.  As  a  matter  of  fact,  the 
patient,  while  masturbating,  rarely  has  pollutions,  for  the 
simple  reason  that  he  does  not  give  his  seminal  vesicles  a 
chance  to  become  distended.  It  is  only  after  he  has  ceased 
the  habit,  and  caused  a  congestion  of  his  prostatic  urethra, 
that,  as  soon  as  his  seminal  vesicles  become  distended,  pol- 
lutions appear.  It  is  often  this  appearance  of  these  pollu- 
tions that  frightens  the  patient,  so  that  he  returns  to  his 
masturbation  or  indulges  in  illicit  coitus. 

Nocturnal  pollutions  are  perfectly  normal  if  they  occur 
at  not  too  frequent  intervals,  and  are  not  accompanied  by 
a  feeling  of  marked  depression.  It  is  difficult  to  state  how 
many  pollutions  a  person  may  have  to  be  within  normal 
limits,  for  the  reason  that  the  sexual  passion  and  desire 
varies  so  much  within  normal  limits.  Furthermore,  a  man 
accustomed  to  coitus  twice  a  week,  and  who  for  various 
reasons  has  remained  continent,  is  entitled  to  more  pollu- 
tions than  one  who  has  been  in  the  habit  of  indulging  only 
once  in  one  or  two  weeks.  As  a  general  thing  it  may  be 
said  that  as  long  as  pollutions  are  only  nocturnal,  and  occur 
with  erect  penis,  not  oftener  than  once  in  ten  days,  and  are 
not  accompanied  by  a  marked  feeling  of  depression,  they 
may  be  considered  normal.  Rohleder^"'^  considers  even  two 
nocturnal  pollutions  a  week  normal.  In  considering  the 
number  of  pollutions,  one  must  not  go  by  the  number  in 


110  Disorders  of  the  Sexual  Function. 

any  particular  week,  but  by  the  average  of  several  weeks. 
Thus,  it  frequently  happens  that  a  patient  may  not  have 
any  pollution  in  seven  or  eight  weeks  and  then  have  two 
or  three  in  one  week,  or  even  in  one  night.  This  condition 
may  still  be  normal,  as  the  average  for  the  eight  or  nine 
weeks  is  within  normal  limits.  Diurnal  pollutions,  as  well 
as  defecation  arid  urination  spermatorrhea,  are  practically 
always  pathological. 

Pathology. — In  order  to  understand  the  pathology  of 
pollutions  we  must  revert  to  the  same  scheme  of  the  modus 
operandi  of  erection  and  ejaculation  which  has  been  given 
under  Impotence. 

We  have  shown  (page  1 1 1 )  that  the  nervous  mechanism 
of  normal  erection  and  ejaculation  is  as  follows.  As  soon 
as  the  desire  for  coitus  arises,  impulses  are  sent  from  C 
(cerebrum)  to  R  (erection  center  in  spinal  cord),  which 
sends  them  through  the  dilator  nerves  to  the  penis  until 
complete  erection  occurs  (i.  c,  dilatation  of  blood-vessels  of 
penis,  etc). 

Now  R  (erection  center)  receives  from  P  (glans  penis 
during  friction  of  coitus)  continuous  new  impulses  which 
serve  to  strengthen  and  keep  up  the  erection.  R  has  also 
the  additional  function  of  keeping  back  a  part  of  the  im- 
pulses it  receives  until  its  cells  are  filled  to  their  utmost 
tension,  and  then  only  to  send  these  impulses  to  E^  (sympa- 
thetic ejaculation  center,  which  causes  the  expulsion  of  the 
secretion  of  the  sexual  glands)  and  also  to  E2  (spinal 
ejaculation  center  which  controls  the  striated  muscular 
fibers).  The  impulses  that  come  from  P  (through  friction 
of  the  glans  penis  during  coitus)  to  R  may  be  weaker,  in 


^ 


m 


Pollutions  in  the  Male. 


Ill 


Diagrammatic   scheme   of   the   nervous   mechanism   of   normal   coitus, 
impotence,  and  pollutions.     (After  Groag.) 

C,  cerebrum;  R,  erection  center;  E\,  sympathetic  ejaculation  center 
(which  causes  the  expulsion  of  the  secretions  of  the  sexual  glands)  ; 
£2,  spinal  ejaculation  center  (which  controls  the  striated  muscular 
fibers)  ;  P,  glans  penis;  V ,  seminal  vesicles.  The  single  arrow  indi- 
cates an  ordinary  impulse ;  the  double  arrow,  a  very  strong  impulse. 
The  transverse  lines  in  R,  in  Figs.  1,  2,  and  3,  indicate  that  R  sends 
out  impulses  to  E\  and  £2  oyily  after  having  been  completely  filed  up 
•with  impulses,  while  in  Fig.  4  we  see  that  R  sends  them  out  before  it 
is  completely  filled  up  with  impulses. 


112  Disorders  of  the  Sexual  Function. 


proportion  as  the  impulses  that  come  from  V  (distended 
seminal  vesicles)  are  stronger.  In  other  words,  with  mark- 
edly distended  seminal  vesicles  we  can  get  normal  coitus 
even  if  there  is  less  friction  of  the  glans  penis,  for  enough 
impulses  are  coming  from  the  seminal  vesicles  to  fill  up  R. 
As  soon  as  R  is  so  filled  up  (so  completely  distended)  with 
impulses  from  C,  P,  and  V  that  they  overflow  to  E,  and 
£2,  ejaculation  takes  place.  In  other  words  the  erection 
center  (i?)  has  two  functions,  first,  to  receive  impulses  from 
the  cerebrum  (C),  the  penis  (F),  and  seminal  vesicles  (F), 
and,  in  the  second  place,  to  hold  back  these  impulses  until 
the  proper  time  and  then  to  send  them  to  the  ejaculation 
centers  (£1  and  E^)  so  that  ejaculation  should  come  at  the 
proper  time  and  not  too  soon. 

Let  us  now  consider  the  physiology  and  pathology  of 
pollutions  according  to  the  above  scheme.  This  is  graphi- 
cally illustrated  in  Fig.  2.  The  diagrams  show  that  Fig.  2 
is  the  same  as  Fig.  i  except  that  the  impulses  from  P  (glans 
penis  during  friction  of  coitus)  are  absent,  while  those  from 
V  (distended  seminal  vesicles)  are  very  strong  (indicated 
by  a  double  arrow). 

We  begin  with  an  overdistention  of  the  seminal  ves- 
icles. As  a  result  of  this,  impulses  are  sent  to  the  central 
nervous  system  and  erotic  dreams  are  formed,  which  are 
generally  made  up  of  the  experiences  of  the  patient.  As  a 
result  of  this  dream,  impulses  are  sent  from  C  to  R  with 
about  the  same  intensity  as  in  normal  coitus  (Fig.  2). 
The  impulses  from  P  are  absent.  For  this  reason,  in  order 
to  thoroughly  distend  the  erection  center  (i?),  the  impulses 
that  run  from   V  to  R   (very  distended  seminal  vesicles 


I 


Pollutions  in  the  Male.  113 


represented  by  a  double  arrow)  must  be  very  strong  in 
order  to  cause  an  overflowing  of  impulses  to  E^  and  E^  and 
allow  ejaculation  to  take  place. 

So  far  this  may  be  perfectly  normal,  if  it  does  not  hap- 
pen at  too  frequent  intervals.    If,  however,  either  as  a  con- 
sequence of  masturbation  or  withdrawal  or  any  of  the  other 
conditions  mentioned  in  the  etiology,  either  the  cells  of  the 
cerebrum   or  the  erection   or  ejaculation   centers   become 
hyperirritable,  the  whole  process  takes  place  at  the  slightest 
provocation   (just  as  in  rapid  ejaculation)    and  it  is  not 
necessary  for  a  distention  of  the  erection  center  {R)  with 
impulses  to  allow  of  ejaculation  as  in  physiological  pollu- 
tion, for  R  is  so  hyperirritable  that,  at  the  slightest  impulse 
from  its  various  sources,  it  sends  impulses  to  the  ejaculation 
centers    {E^   and  E^)    and   immediately  ejaculation  takes 
place.     The  ejaculation  centers  may  also  become  hyperirri- 
table and  go  off  at  the  slightest  provocation.     The  cells  of 
the  cerebrum  (C)  may  become  hyperirritable  likewise,  and 
send  to  the  erection  center  powerful  impulses  at  the  slightest 
suggestion  of  an  erotic  thought.     Finally,  just  as  in  impo- 
tence, we  may  get  an  exhaustion  of  all  the  centers  so  that 
they  will  refuse  to  respond  to  any  impulse.    The  pollutions 
become  less  and  less  frequent  (without  any  treatment)  and 
at  length  stop  altogether.     The  patient  considers  himself 
improving  and  finally  well,  but,  as  a  matter  of  fact,  he  is 
getting  worse.     Should  such  a  patient  at  this  stage  attempt 
coitus  he  will  find  himself  impotent.     But  this  will  be  con- 
sidered more  in  detail  in  giving  the  symptoms. 

The  pathology  of  diurnal  pollutions  is  similar,  and  is 
diagrammatically  illustrated  in  Fig.  3.     Sometimes  in  the 


114  Disorders  of  the  Sexual  Function. 


waking  state,  in  the  presence  of  markedly  distended  seminal 
vesicles,  strong  long-continuing  lascivious  irritations  may 
lead  to  strong  erection  and  ejaculation.  In  Fig.  3  we  notice 
the  same  condition  as  in  Fig.  2  except  that  the  impulses 
which  come  from  the  cerebrum  (C)  are  exceedingly  power- 
ful  (represented  by  a  double  arrow).  Groag^^  considers 
this  condition  physiological,  but  I  believe  that  in  the  waking 
state  there  ought  normally  to  be  enough  inhibitory  impulses 
present  to  prevent  ejaculation.  However  this  may  be,  there 
is  no  doubt  that  if,  as  in  the  former  class  of  cases,  the 
centers  become  hyperirritable,  so  that,  as  sometimes  occurs, 
the  mere  sight  of  a  pretty  woman,  or  the  mere  touching 
of  a  woman  in  a  crowded  car,  is  enough  to  bring  on  an 
ejaculation,  such  a  condition  is  to  be  considered  markedly 
pathological. 

That  the  seminal  vesicles  play  the  part  described  in  the 
above  condition  has  been  proved  experimentally,  by  Tarch- 
anoff,  in  frogs.  If  he  squeezed  out  the  contents  of  the 
seminal  vesicles  in  these  animals,  they  lost  all  desire  for 
coitus,  but  if  he  distended  them  with  sperm  from  other 
frogs  or  even  water,  the  desire  immediately  returned. 

The  local  pathology  is  similar  to  that  found  in  withdrawal 
or  masturbation.  There  may  be  the  same  local  conditions 
present  in  the  posterior  urethra  as  have  been  mentioned  in 
these  latter  conditions.  As  stated  heretofore,  one  cannot 
make  a  diagnosis  of  either  masturbation,  withdrawal  or 
pollutions,  by  merely  looking  through  the  urethroscope. 
All  that  the  urethroscope  reveals  is  the  pathological  con- 
dition present  in  the  posterior  urethra,  and  this  condition 
may  be  the  result  of  widely  different  causes.     Similarly, 


Pollutions  in  the  Male. 


115 


any  pathological  condition  in  the  posterior  urethra  or  pros- 
tate or  seminal  vesicles,  whether  the  result  of  gonorrhea, 
masturbation,  withdrawal,  maltreatment  of  the  urethra  or 
any  other  condition  powerful  enough  to  start  reflexes  to 
the  cerebrum  or  erection  centers,  may  be  the  cause  of^ 
pollutions. 

Finally  we  must  state  that  the  local  conditions  may  be 
absolutely   normal,    and   still    pathological   pollutions    may 
take  place.     It  has  been  stated  above  that  for  pathological 
pollutions  to  occur,  there  must  be  present  a  hyperirritable 
condition  either  of  the  cells  of  the  cerebrum  or  of  the  sex- 
ual centers,   or  of  the  local  pathological  condition  of  the 
genital  organs  (congestion,  etc.,  in  the  prostatic  urethra). 
-All  of  these  conditions  need  not   be  present  to   cause  a 
pollution,  and  it  not  infrequently  happens  that  with  a  per- 
fectly normal  posterior  urethra,  as  seen  through  the  endo- 
scope, pollutions  may  occur.     As  an  example  of  such  a 
condition  we  may  mention  cases  where  the  patient  has  his 
thoughts  continually  upon  sexual  matters,  and  is  constantly 
reading  erotic  literature,  or  seeking  the  presence  of  female 
companionship,  while  not  actually  indulging  in  sexual  inter- 
course.    Such  a  patient  can  so  excite  his  cerebrum  that 
pollutions  will  occur  from  that  cause  alone.     If  this  con- 
tinues for  a  long  time,  however,  there  generally  results  also 
a  local  congestion  of  the  sexual  apparatus  in  the  same  way 
as  in  masturbation,  withdrawal,  and  similar  conditions. 

When  we  come  to  the  pathology  of  defecation  sperma- 
torrhea, we  find  a  marked  difference  of  opinion  among  the 
authorities.  The  earlier  writers  claim  that  it  was  the  result 
of  the  mechanical  squeezing  out  of  the  contents  of  the  sem- 


116  Disorders  of  the  Sexual  Function     ^ 

inal  vesicles  by  the  passage  of  the  fecal  mass.     Of  late, 
however,  there  has  been  a  tendency  to  discredit  this  theory. 
Peyer  objects  to  it  from  the  anatomical  position  of  the 
seminal  vesicles,  which,  he  claims,  because  of  their  position 
between  the  rectum  and  the  bladder,  would  be  pushed  out 
of  the  way  by  the  hardened  fecal  mass,  and  not  be  directly 
pressed  upon.     Sturgis^^^  believes  it  to  be  due,  not  to  the 
pressure  on  the  seminal  vesicles  by  hardened  feces,  but  to 
the  mechanical  pressure  of  the  abdominal  muscles  incident 
to  this  act.     Rohleder^^^  considers  the  condition  to  be  due 
to  a  paralysis  of  the  ejaculatory  ducts,  and  says  that  def- 
ecation spermatorrhea  is  caused  by  a  mechanical  squeezing 
out  of  the  semen  from  the  seminal  vesicles  due  to  weakness 
and  insufficiency  of  the  sphincters  of  the  seminal  vesicles 
and  the  ejaculatory  ducts.     He  is  of  the  opinion  that  with 
normal  sphincters  the  hardest  defecation  will  not  be  able  to 
cause  spermatorrhea.    Ultzmann  compares  nocturnal  pollu- 
tions to  spasm  of  the  bladder,  and  defecation  or  urination 
spermatorrhea  to  paralysis  of  the  bladder,  and  says  that 
nocturnal  pollutions  are  really  spasms  of  the  seminal  ves- 
icles due  to  overdistention,  whereas  defecation  and  urination 
spermatorrhea  is  due  to  a  paralysis  of  the  ejaculatory  ducts. 
I  am  inclined  to  disagree  with  Rohleder  and  the  other 
authorities  just  mentioned,  in  their  conception  of  nocturnal 
(or  diurnal)   pollutions  on  the  one  hand,  and  defecation 
and  urination  spermatorrhea  on  the  other.     My  dissent  is 
based  entirely  upon  clinical  experience.    If  nocturnal  pollu- 
tions were  solely  the  result  of  contractions  of  the  muscles 
of  the  seminal  vesicles,  or,  as  Ultzmann  puts  it,  spasm  of 
the  overdistended  seminal  vesicles,  it  would  hardly  be  con- 


Pollutions  in  the  Male.  117 

ceivable  that  they  should  recur  as  frequently  as  they  do,  for 
clinically  it  is  not  unusual  for  them  to  occur  two,  three, 
four,  or  even  more  times  a  week,  sometimes  three  a  night. 
One  would  imagine  that  after  one  or  two  emissions  the 
seminal  vesicles  would  be  nearly  empty,  and  certainly  not 
overdistended.  Then,  if  overdistention  were  the  only  cause 
of  nocturnal  pollutions,  pollutions  would  be  more  common 
in  married  men  (unless  coitus  is  very  frequently  indulged 
in)  than  in  single  men,  whereas  just  the  reverse  is  the  case. 
But  to  my  mind  the  clinical  therapeutical  result  is  of  most 
importance.  As  will  be  shown  later  on,  in  discussing  the 
treatment  of  the  condition,  the  most  severe  cases  of  noc- 
turnal pollutions  yield  rapidly  to  the  action  of  the  bromides. 
I  have  yet  to  see  a  case  of  nocturnal  pollution  that  did  not 
yield  (temporarily  at  least)  to  the  administration  of  this 
drug.  If,  therefore,  nocturnal  pollutions  were  purely  due 
to  a  spasm  of  the  seminal  vesicles,  it  is  inconceivable  that 
a  drug  which  has  no  effect  whatsoever  upon  local  muscular 
spasm,  but  acts  only  by  quieting  the  cells  of  the  cerebrum 
and  possibly  the  reflex  centers  in  the  spinal  cord  (although 
many  neurologists  even  doubt  this  latter  action),  could  so 
uniformly  have  such  good  results. 

Another  clinical  observation,  w^hich  I  have  made,  like- 
wise refutes  the  theory  that  a  spasm  of  the  distended  sem- 
inal vesicles  is  responsible  for  nocturnal  pollutions.  In 
cases  of  chronic  gonorrhea  I  have  very  often  had  occasion 
to  frequently  massage  the  prostate  and  strip  the  vesicles, 
either  for  diagnosis  or  treatment.  As  an  invariable  rule, 
this  procedure,  if  frequently  repeated,  will  bring  on  noc- 
turnal pollutions  where  none  had  previously  existed,  and 


118  Disorders  of  the  Sexual  Function. 


wiU  markedly  increase  the  number  of  pollutions  where  they 
had  existed  only  to  a  physiological  degree.  If  spasm  due 
to  distention  of  these  organs  causes  pollutions,  it  should 
naturally  follow  that  emptying  them  ought  to  have  just  the 

opposite  effect. 

I  have  given  the  physiology  and  pathology  of  pollutions 
heretofore,  and  pointed  out  in  that  connection  that  the  way 
distended  vesicles  act  is  not  by  a  local  spasm,  but  by  reflex 
action  alone,  namely,  by  sending  normal  impulses  to  the 
erection  center,  just  as  pathological  impulses  are  sent  thither 
from  a  congested  posterior  urethra,  and  that,  as  a  result 
of  these  impulses  plus  other  impulses  which  the  erection 
center  receives  from  various  sources  (J.  e.,  cerebrum,  penis, 
etc.),  this  center  sends  impulses  to  the  ejaculation  centers 
which  result  in  ejaculations  or  pollutions,  as  the  case  may 
be.     In  massage  of  the  prostate  and  stripping  of  the  ves- 
icles, we  irritate  these  parts  and  send  impulses  to  the  erec- 
tion'center   in   the   same   manner.      This   pathology   also 
explains  the  beneficial  effects  of  the  bromides  on  pollutions. 
In  defecation  spermatorrhea  I  must  likewise  disagree 
with  Rohleder,  and  again  on  purely  clinical  grounds.   When 
Rohleder  says  that,  with  normal  sphincters  of  the  seminal 
vesicles  and  ejaculatory  ducts,  the  hardest  defecation  cannot 
bring  about  a  discharge  from  these  organs,  and  when  Peyer 
tries  to  prove  the  same  thing  from  a  consideration  of  the 
anatomical  position  of  the  seminal  vesicles,  the  following 
clinical  evidence  may  be  presented  in  direct  contradiction: 
I  have  had  occasion  in  very  many  instances  to  strip  the 
seminal  vesicles  in  cases  of  chronic  gonorrhea,  either  for 
diagnostic  or  therapeutic  purposes.     In  most  of  these  cases, 


Pollutions  in  the  Male.  119 

no  pollutions  or  defecation  or  urination  spermatorrhea  was 
present;  and  yet,  I  have  never  failed  to  obtain  a  specimen 
from  the  prostate  and  vesicles  for  examination.  In  every 
case  was  I  able  to  bring  one  or  more  drops  (sometimes 
a  large  quantity)  of  the  secretions  of  these  organs  to  the 
meatus.  If,  then,  in  normal  persons,  with  presumedly  nor- 
mal seminal  vesicle  sphincters,  by  simple  pressure  on  the 
seminal  vesicles  with  the  finger-tips  in  the  rectum,  we  can 
cause  a  discharge  of  their  contents,  why  cannot  a  hard 
fecal  mass  in  the  same  place  do  likewise?  Furthermore,  it 
often  occurs  that,  in  some  cases,  the  slightest  touch  on 
these  parts  would  bring  forth  a  very  large  amount  of  sem- 
inal secretion  (proven  so  by  the  microscope)  where  we 
would  imagine  that  there  must  exist  a  very  marked  paral- 
ysis of  the  ejaculatory  ducts  or  musculature  of  the  seminal 
vesicles  and  its  sphincters,  and  yet  these  patients  have  not 
been  subject  to  defecation  or  urination  spermatorrhea  or 
even  to  nocturnal  pollutions.  I  can  neither  affirm  nor  deny 
that  in  defecation  or  urination  spermatorrhea  there  exists 
an  insufficiency  of  the  sphincters  of  the  seminal  vesicles, 
and  certainly  the  clinical  evidence  is  not  sufficient  to  sustain 
this  view.  Those  that  uphold  it  have  brought  forth  no 
evidence  except  their  own  theoretical  opinion.  To  my 
mind,  it  is  still  an  open  question  whether  defecation  or 
urination  spermatorrhea  is  due  to  a  reflex  action  set  up  by 
the  act  of  defecation  or  urination,  or  whether  it  is  due  to 
insufficiency  of  the  musculature  of  the  seminal  vesicles  or 
ejaculatory  ducts,  or  due  to  the  mechanical  pressure  of 
hardened  feces  or  to  the  mechanical  action  of  the  abdominal 
muscles  upon  the  seminal  vesicles.    In  urination  spermator- 


120  Disorders  of  the  Sexual  Function. 

rhea,  it  is  supposed  that  the  muscular  action  incident  to 
pressing  out  the  last  drops  of  urine  also  presses  on  the  sem- 
inal vesicles  and  squeezes  out  part  of  their  contents.  As 
stated  above,  Sturgis^^*^  inclines  to  the  view  that  defecation 
spermatorrhea  is  due  to  the  mechanical  action  of  the  ab- 
dominal muscles  incident  to  defecation,  and  cites  in  proof 
that  the  same  condition  may  be  produced  by  such  acts  as 
coughing  and  sneezing,  but  I  have  never  seen  such  cases. 

Some  authors  claim  to  have  seen  through  the  endoscope, 
in  cases  of  pollutions,  the  mouths  of  the  ejaculatory  ducts 
widely  dilated,  thus  proving  the  paralytic  condition  of  the 
ejaculatory  ducts.  I  have  for  several  years  made  endo- 
scopic examinations  of  the  posterior  urethra  in  cases  of 
pollutions,  using  both  the  Wossidlo-Goldschmidt  and 
Buerger  instruments,  but  cannot  subscribe  to  the  observa- 
tions of  these  writers.  I  have  found  the  most  marked 
differences  in  the  appearances  of  the  mouths  of  the  ejacu- 
latory ducts,  not  only  in  pathological  but  also  in  normal 
cases,  and  am  certain  that  in  pollutions  these  ducts  are 
found  on  the  average  no  more  dilated  than  they  are  in  other 
pathological  or  even  normal  conditions.  As  so  often  em- 
phasized, one  cannot  make  a  diagnosis  of  pollutions  with 
the  endoscope. 

The  pathology  of  urcthrorrhoea  ex  libidine  sexuale  is 
entirely  different  from  the  other  forms  of  pollution.  Here 
there  is  simply  an  overactivity  of  Cowper's  glands  and 
those  of  the  urethra.  Normally,  at  the  very  commencement 
of  coitus,  Cowper's  glands,  as  well  as  the  glands  and  fol- 
licles of  the  urethra,  pour  out  their  secretions  into  the 
urethra  in  order  to  remove  the  acidity  which  is  generally 


Pollutions  in  the  Male.  i9j^ 


present  there  on  account  of  moisture  from  urine,  and  which 
would  be  inimical  to  the  vitality  of  the  spermatozoa.  In 
cases  of  urethrorrhea,  there  is  an  overactivity  of  these 
glands,  so  that  the  merest  act  of  flirtation,  or  spooning,  or 
even  erotic  thoughts,  are  sufficient  to  cause  these  glands  to 
pour  out  their  secretions,  which  then  appear  at  the  meatus. 
The  condition  is  simply  due  to  too  great  a  response  on  the 
part  of  these  glands  to  central  stimulation. 

Symptoms. -It  not  infrequently  happens  that  quacks 
for  their  own  selfish  purposes,  grossly  exaggerate  the  symp- 
toms of  normal  pollutions.     To  offset  this  influence,  some 
reputable  physicians  have  thought  it  expedient  to  underrate 
the  seriousness  of  pathological  pollutions,  and  tell  the  pa- 
tients that  any  pollution  is  of  no  importance  whatsoever 
and  that  the  whole  trouble  is  imaginary.    Nothing  could  be 
further  from  the  truth.    Any  one  who  has  seen  the  marked 
neurasthenic  symptoms  that  accompany  severe  pathological 
pollutions,  even  in  patients  with  no  underlying  history  of 
general  neurasthenia,  and  how  their  general  condition  im- 
proves, and  their  whole  psychic  is  changed,  with  the  ces- 
sation of  the  pollutions,  will  appreciate  that  pollution  is  a     " 
very  important  condition  and  sometimes  a  very  serious  one, 
which  demands  our  most  earnest  attention. 

In  normal  cases  the  patient  experiences  during  the  night 
an  erotic  dream,  which  is  accompanied  by  an  erection  of 
the  perns  and  ejaculation.  He  is  generally  awakened  during 
the  process  of  ejaculation.  Sometimes,  however,  he  con- 
tinues m  his  sleep,  and  upon  awakening  in  the  morning 
discovers  that  he  has  had  an  emission.  In  some  cases  no 
dream  accompanies  the  ejaculation,  or  at  least  is  not  remem- 


122  Disorders  of  the  Sexual  Function. 


bered  by  the  patient.  Normally  these  emissions  do  not 
occur  on  the  average  more  than  once  in  ten  days,  and 
always  occur  with  erection.  They  are  not  accompanied  by 
any  marked  feeling  of  depression,  sometimes,  indeed,  quite 
the  reverse,  with  a  feeling  of  contentment. 

It  often  happens  that  the  young  man  is  frightened  by 
this  emission,  thinking  that  he  is  losing  his  semen,  that  he 
will  become  impotent,  and  that  the  condition  is  due  to  his 
"youthful  errors"  of  perhaps  very  many  years  before. 
Sometimes,  without  consulting  a  physician,  he  indulges  in 
illicit  coitus,  thinking  that  the  onset  of  the  emissions  is  a 
sign  that  coitus  must  be  indulged  in.  In  this  way  he  may 
become  infected  with  venereal  disease. 

If  he  is  wise  he  will  consult  his  physician,  who  will  give 
him  the  proper  advice.  If  he  is  foolish,  however,  which  is 
more  often  the  case,  he  will  seek  out  one  of  the  many 
advertising  quack  physicians,  who  will  not  only  confirm  all 
his  fears  of  impotence,  "lost  manhood,"  etc.,  but  will 
frighten  him  more,  call  his  attention  to  a  normal  sediment 
in  his  urine,  explain  to  him  that  his  vital  fluid  is  being 
sapped  out  of  him,  etc.,  and  may,  and  indeed  very  often 
does,  make  of  him  a  confirmed  sexual  neurasthenic,  watch- 
ing himself  closely,  continually,  and  exaggerating  every 
little  pain  or  ache.  I  get  these  patients  in  large  numbers 
at  my  dispensary  clinic,  after  they  have  been  relieved  of  all 
their  savings  by  quacks,  and  it  often  takes  considerable 
argument  and  tact  to  prove  to  these  normal  cases  that  they 
are  not  going  to  perdition. 

The  symptoms  of  pathological  pollutions  are  somewhat 
different.     The  patients  have  pollutions  two  or  three  times 


Pollutions  in  the  Male.  123 


a  week,  often  without  erection.  After  the  pollutions  they 
complain  of  marked  nen^ous  symptoms  and  a  feeling  of 
depression  to  be  described  hereafter.  The  pollutions,  if 
untreated,  may  even  increase  in  frequency,  but  after  a  while 
they  diminish  and  finally  cease  altogether  without  any  treat- 
ment whatsoever.  This  the  patient  considers  a  very  good 
sign,  but  as  a  matter  of  fact  it  is  just  the  reverse.  It 
means,  as  explained  in  the  pathology,  that  the  sexual  cen- 
ters have  become  completely  exhausted,  and  fail  to  respond 
to  any  stimuli.  Such  patients,  at  this  stage,  will  find  them- 
selves impotent. 

The  dreams  that  accompany  pollutions,  both  normal  and 
pathological,  are  very  interesting  and  instructive.     Porosz^^ 
has  called  attention  to  the  fact  that  very  often  we  can  tell 
the  course  of  the  disease  by  the  character  of  the  dreams 
which  accompany  the  pollutions.     The  dream  is  frequently 
an  index  of  the  potency  of  the  individual.    In  normal  cases, 
in  persons  who  have  already  indulged  in  sexual  intercourse,' 
the  dream  is  often  an  exact  counterpart  of  the  act  of  coitus' 
The  patient  dreams  of  courtship  and  spooning  with  a  female, 
then  the  retiring,  the  preparation  for  coitus  by  both  parties,' 
the  erection,  the  insertion  of  the  penis  into  the  vagina,  the 
friction,  and  finally  the  ejaculation.     The  time  between  the 
commencement  of  the  dream  and  the  ejaculation  is  a  com- 
paritively  long  one.     In  pathological  cases,  as  the  disease 
progresses,   this  time  becomes  shorter  and  shorter.     The 
patient  dreams  of  spooning  and  coitus  as  above,  but  the 
ejaculation  occurs  at  the  very  first  attempts  of  coitus,  and 
finally  the  patient  only  dreams  of  spooning,  and  wakes  up 
at  once  with  an  ejaculation.     Even  in  normal  cases,  where 


124  Disorders  of  the  Sexual  Function. 


two  or  three  dreams  occur  in  one  week,  the  first  dream 
may  be  a  very  lengthy  one,  as  the  first  above  described, 
while  the  latter  ones  become  progressively  shorter. 

I  have  paid  particular  attention  to  these  sexual  dreams, 
and  in  many  cases  have  obtained  a  typical  history  just  like 
those  recited.  Often,  however,  especially  in  dispensary 
cases,  the  patients  are  too  ignorant  to  give  a  sensible  his- 
tory of  their  dreams,  and  frequently,  even  in  intelligent 
patients,  the  patients  forget  their  dreams.  The  woman  in 
the  dream  is  generally  one  with  whom  the  patient  is  ac- 
quainted, often  the  cousin  or  sweetheart,  or  it  may  be  some 
stranger  who  happens  to  have  made  an  impression  upon 
the  patient.  Sometimes  the  patient  does  not  dream  of  coitus 
at  all,  but  of  masturbating.  Very  often,  also,  the  patient 
does  not  dream  of  women  at  all,  but  of  some  other  object, 
the  sexual  nature  of  which  can  be  explained  by  those  versed 
in  the  Freudian  theory. 

As  a  practical  point,  and  one  which  I  do  not  recall  hav- 
ing seen  recorded  anywhere,  I  have,  for  some  time  past, 
determined  the  patient's  veracity  as  to  his  sexual  experience 
by  the  nature  of  his  pollution  dreams.  In  my  clinic  I 
frequently  encounter  young  adults  who  come  for  treatment 
of  pollutions,  and,  upon  the  routine  questionings,  tell  me 
that  they  have  never  indulged  in  coitus.  Inquiring  later 
on  as  to  the  nature  of  their  pollution  dreams  they  inform 
me  that  they  dream  of  having  coitus  with  a  woman.  In 
this  case  I  immediately  infer  that  the  patient  has  had  ex- 
perience in  coitus,  and  almost  always  can  obtain  his  confes- 
sion in  this  regard.  With  the  exceptions  later  mentioned, 
07ie  cannot  dream  of  coitus  unless  he  has  indulged  in  coitus. 


Pollutions  in  the  Male.  125 

We  must  be  careful,  however,  in  jumping  at  conclusions 
and  must  go  particularly  into  the  history  of  the  dream. 
For  instance,  I  had  one  young  man  who  told  me  that  he 
had  never  indulged  in  coitus,  but  in  his  pollution  dream.s 
dreamt  that  he  had  connection  with  a  woman.  I  asked  him 
to  describe  his  dream,  and  from  his  description  saw  that 
the  man  "had  the  most  ridiculous  notion  what  the  act  of 
coitus  consisted  of.  In  other  words,  this  young  m.an,  who 
had  really  been  continent,  dreamt  of  what  to  his  mind  was 
the  act  of  coitus.  In  another  case,  upon  careful  questioning, 
I  was  told  by  the  boy  that  he  had  seen  in  the  park  a 
couple  indulge  in  coitus,  and  this  picture  came  to  him  as 
a  pollution  dream.  Another  young  man  informed  me  that 
he  had  seen  in  Paris,  at  a  "private"  motion-picture  theater, 
the  entire  act  of  coitus  portrayed  upon  the  screen.  In 
many  cases  the  boy's  impression  of  coitus  comes  from  the 
particular  literature  he  indulges  in,  or  from  knowledge 
obtained  from  older  persons,  and  in  his  pollution  dreams 
the  act  of  coitus  is  according  to  his  knowledge  of  the  sub- 
ject. So  that,  while  the  rule  just  laid  down,  that  one 
cannot  dream  of  coitus  unless  he  has  indulged  in  it,  is  gen- 
erally true,  we  must  go  into  all  the  experiences  of  these 
patients  in  order  to  draw  proper  conclusions. 

Diurnal  pollutions  I  consider  to  be  always  pathological. 
They  are  most  generally  present  in  patients  who  also  suffer 
from  nocturnal  pollutions.  Indeed,  it  is  rather  rare  to  find 
patients  who  only  suffer  from  diurnal  pollutions.  In  these 
cases  the  very  sight  of  a  woman,  or  the  rubbing  up  against 
one  in  a  crowded  car,  is  sufficient  to  cause  an  ejaculation 
of  semen.    In  the  vast  majority  of  these  cases  there  is  very 


126  Disorders  of  the  Sexual  Function. 


slight,  if  any,  erection.  Sometimes  the  patient  sees  fluid 
appearing  at  his  meatus  every  time  he  looks  at  it.  This 
latter  represents  a  much  more  severe  type  of  pollution  than 
either  the  nocturnal  or  the  diurnal  with  erection. 

In   defecation   spermatorrhea  the  patient  notices   that 
during   the   straining   incident   to   defecation   a   discharge 
appears  and  runs  out  of  the  urethra.     The  quantity  varies 
from  a  few  drops  to  a  dram.     I  must  remark,  here,  how- 
ever, that  the  patient's  word  as  to  quantity  of  fluid  lost 
in  pollutions  of  all  kinds  must  be  taken  with  a  large  grain 
of  salt,  as  they  are  generally  prone  to  exaggerate.    In  mild 
cases  these  losses  accompany  only  severe  straining  efforts, 
or  the  passage  of  very  hard  fecal  masses,  whereas  in  the 
more  severe  cases  they  appear  with  every  defecation,  even 
when  the  fecal  contents  have  been  artificially  made  soft  and 
watery  by  mineral  cathartics,  and  are  unaccompanied  by 
any  straining  whatsoever.     As  a  matter  of  clinical  experi- 
ence, I  have  frequently  noticed  these  severe  cases  of  defeca- 
tion'spermatorrhea   to   be   the   forerunners    of   the   most 
obstinate  cases  of  impotence,  and  conversely,  in  many  cases 
of  impotence  that  come  to  me  for  treatment,  I  have  also 
obtained  a  history  of  defecation  spermatorrhea. 

In  urination  spermatorrhea  the  patient  notices,  after 
urination,  a  seminal  discharge.  Patients  with  urination 
spermatorrhea  almost  always  suffer  from  nocturnal  pollu- 
tions at  the  same  time,  and  very  often  are  afflicted  also  with 
defecation  spermatorrhea.  This  represents,  to  my  mind, 
the  severest  type  of  pollutions  and  is,  of  course,  always 
pathological.  As  previously  stated,  it  makes  no  difference 
whether  spermatozoa  are  found  in  the  discharge  or  not. 


Pollutions  in  the  Male.  127 

The  general  symptoms  of  pathological  pollutions  vary 
greatly  in  intensity.  They  are  especially  severe  in  patients 
with  an  underlying  neurasthenic  tendency.  W^hile  patients 
suffering  from  pathological  pollutions  are  very  prone  to 
exaggerate  the  importance  of  their  symptoms,  especially  if 
they  have  read  profusely  the  quack  literature  on  the  sub- 
ject, we  must  not  fall  into  the  opposite  error  of  thinking 
that  they  have  no  symptoms  at  all,  and  that  their  sufferings 
are  only  imaginary.  I  cannot  too  strongly  emphasize  the 
fact  that  these  patients  have  real  s}TTiptoms  and  that  at  times 
their  sufferings  are  extremely  severe.  As  in  masturbation, 
we  must  here  also  determine  whether  the  symptoms  com- 
plained of  by  the  patient  are  really  experienced  by  him,  or 
whether  they  are  merely  being  repeated  by  him  from  the 
quack  literature  he  has  read. 

One  of  the  symptoms  most  frequently  complained  of  is 
a  peculiar  feeling  of  lassitude,  of  diminished  energy  after 
the  occurrence  of  a  pollution.  The  patient  wakes  up  dead 
tired,  without  any  ambition,  with  no  inclination  for  work, 
and  feels  as  if  he  has  been  up  all  night  doing  hard  work. 
He  is  entirely  exhausted  and  fit  for  sleep  rather  than  for 
the  duties  of  the  day.  This  peculiar  feeling,  which  it  is 
very  difficult  to  describe  in  cold  print,  Is  very  characteristic 
of  pathological  pollutions,  and  is  entirely  different  from  the 
sensations  of  a  chronic  masturbator  or  any  other  form  of 
sexual  neurasthenia. 

Headache  is  another  symptom  often  complained  of,  but, 
as  in  all  forms  of  sexual  neurasthenia,  we  must  determine 
by  competent  authorities  whether  the  headache  may  not  be 
due  to  errors  in  refraction.    In  fact,  every  symptom  of  the 


128  Disorders  of  the  Sexual  Function. 

sexual  neurasthenic  must  be  investigated,  with  the  possi- 
bility in  mind  of  some  other  coexisting  pathological  con- 
dition being  present  to  account  for  the  symptom.  While 
admitting  that  the  sufferer  from  pollutions  is  liable  to  many 
and  severe  symptoms,  we  must  not  fall  into  the  error  of 
blaming  everything  he  complains  of  on  his  pollutions. 

Among  the  other  more  common  symptoms  may  be  men- 
tioned burning  of  the  eyes,  discomfort  in  the  inguinal 
regions,  heaviness  of  the  testicles,  a  feeling  of  faintness 
and  palpitation  of  the  heart,  excessive  perspiration,  pain 
down  the  spine,  and  tremor  of  the  hands.  Loss  of  memory 
is  frequently  complained  of,  but  upon  careful  investigation 
it  will  be  found  not  to  exist.  Very  often,  however,  there  is 
a  temporary  weakness  of  memory  due  to  indiscriminate  use 
of  bromides  or  an  idiosyncrasy  for  this  drug.  Exception- 
ally, we  find  patients  who  come  for  other  troubles,  and 
whose  history  shows  that  they  are  subject  to  frequent  pol- 
lutions, but  apparently  have  no  symptoms  therefrom  and 
do  not  bother  about  them.  I  have  also  noticed  patients  who 
have  suffered  from,  pollutions  for  many  years,  and  in  whom, 
at  the  beginning,  the  pollutions  were  accompanied  by  marked 
general  nervous  symptoms,  but  who,  later  on,  seemed  to 
become  immune  as  it  were,  or  callous,  indifferent  or  apa- 
thetic and  therefore  did  not  suffer  much  from  them. 

In  ordinary  cases  of  pollutions  the  sexual  powers  of 
the  patients  do  not  suffer  much,  if  any;  yet,  from  a  careful 
observation  of  many  cases,  I  am  firmly  convinced  that 
finally  there  occurs  an  impairment  and  temporary  impotence 
in  quite  a  number  of  cases.  However,  the  condition  is  not 
nearly  as  bad  as  some  authors  try  to  make  us  believe,  and 


Pollutions  in  the  Male.  129 


I  am  certain  that  in  many  cases  these  authors  have  mis- 
judged or  have  not  thoroughly  studied  the  symptoms  and 
history.  It  is  undoubtedly  true  that  many  sufferers  from 
impotence  suffer  from  pollutions  also ;  in  fact,  the  two  con- 
ditions may  be  due  to  the  same  pathological  condition  or 
have  the  same  common  etiology,  but  this  does  not  mean 
that  the  impotence  was  the  result  of  the  polliitions. 

Among  the  urinary  symptoms  which  often  accompany 
pollutions,  but  which  are  often  due  to  the  same  condition 
in  the  posterior  urethra  which  is  the  cause  of  the  pollutions, 
may  be  mentioned  frequency  of  urination,  scalding  of  uri- 
nation, and  a  feeling  of  wishing  to  pass  more  urine  after 
the  bladder  has  been  thoroughly  emptied.  Such  a  condition 
as  mentioned  by  Sturgis^^o  as  shrivelled  penis  due  to  pollu- 
tions, I  have  never  seen. 

The  list  of  symptoms  just  given  are  simply  symptoms 
which  one  hears  complained  of,  on  going  carefully  into  the 
history  of  many  cases.  I  do  not  by  any  means  mean  to 
infer  that  any  one  patient  complains  of  all  or  a  majority 
of  these  symptoms.  We  may  find  a  few  or  many  of  the 
symptoms  in  any  particular  case,  as  well  as  any  combi- 
nation of  symptoms. 

It  is  interesting  to  note  what  symptoms  have  been  put 
down  by  some  authorities  as  due  to  pollutions.  Space  will 
not  permit  me  to  mention  all  those  which  have  been 
ascribed  to  this  condition  by  one  authority  or  another.  The 
more  unusual  ones  mentioned  are :  diMculty  in  articulation, 
thickness  of  speech,  burning  and  tingling  at  the  end  of  the 
tongue,  impaired  taste,  epistaxis,  catarrhal  discharge  from 
the  nose,  salivation,  tinnitus  aurium,  partial  deafness,  defec- 


130  Disorders  of  the  Sexual  Function. 


five  accommodation,  temporary  hyperesthesia  of  the  audi- 
tory nerve,  asthmatic  breathing;  a  constant,  short,  hacking 
cough;  cardiac  palpitation,  inter  mitt  ence  in  the  action  of  the 
heart  and  pidse,  angina  pectoris  nervosa,  etc. 

In  urethrorrhoca  ex  libidine  sexuale  the  symptoms  are 
somewhat  different.  In  this  condition,  as  I  understand  it, 
there  is  simply  a  hypersecretion  of  Cowper's  glands  and 
those  of  the  urethra.  The  patient,  after  a  prolonged  act 
of  spooning,  or  other  unsatisfied  sexual  excitement,  will  find 
some  fluid  just  within  or  coming  out  of  the  meatus.  Gen- 
erally a  prolonged  period  of  erection  has  preceded  this 
event,  but  there  has  been  no  coitus  and  no  ejaculation. 
There  is  no  force  behind  this  fluid ;  it  simply  dribbles  out. 
It  is,  as  a  general  thing,  not  accompanied  by  any  feeling  of 
depression  or  other  general  nervous  symptom  unless  the 
patient  has  been  frightened  by  reading  quack  literature. 

Diagnosis  of  Pollutions. — The  main  point  is  to  distin- 
guish between  normal  and  pathological  pollutions.  The 
differential  points  are  as  follows:  Normal  pollutions  are 
always  nocturnal,  whereas  pathological  pollutions  may  be 
either  nocturnal  or  diurnal,  and  may  accompany  defecation 
or  urination.  Normal  pollutions  occur  on  the  average  not 
oftener  than  once  in  ten  days,  whereas  pathological  pollu- 
tions occur  much  more  frequently.  Normal  pollutions 
always  occur  with  strong  erection  of  the  penis,  whereas 
pathological  pollutions  occur  with  very  weak  or  no  erection 
at  all.  Normal  pollutions  are  generally  not  followed  by  a 
marked  period  of  depression,  whereas  pathological  pollu- 
tions are  generally  followed  by  such  a  feeling. 

It  might  seem  ridiculous  to  state  that  pollutions  should 


Pollutions  in  the  Male. 


131 


not  be  confounded  with  gonorrhea,  but  I  have  seen  such 
mistakes  made  in  not  a  few  cases.     In  several  instances,  I 
have  seen  careless  dispensary  physicians  prescribe  for  cases 
without  any  examination  of  the  genitals  at  all,  and  the 
mere  fact  that  a  patient  comes  into  the  dispensary  complain- 
ing of   "running-   or   ''discharge"    is   sufficient  for  them, 
without  further  examination,  to  conclude  that  the  patient 
is  suffering  from  gonorrhea  and  prescribe  accordingly.     In 
my  private  practice,  also,  I  have  had  patients  come  with 
diurnal  or  urination  spermatorrhea,  who  had  been  treated 
for  gonorrhea  by  some  careless  physician.     As  a  general 
thing  the  secretion  which  appears  at  the  meatus  in  cases  of 
dmrnal  pollutions  or  urethrorrhea  is  entirely  different  in 
appearance  from  that  of  an  acute  or  even  chronic  gonor- 
rheal discharge,  but,  aside  from  this  difference  in  appear- 
ance,   no   physician   should   treat   any   urethral    discharge 
without   first    subjecting    it    to    microscopic    examination. 
Even  if  no  gonococci  are  found,  the  other  characteristics  of 
the  discharge  under  the  microscope  are  sufficient  to  dif- 
ferentiate the  conditions. 

Prognosis.— The  prognosis  of  normal  pollutions  is  of 
course,  excellent.  In  pathological  nocturnal  pollutions  the 
prognosis  is  very  good  also.  \Y^  must  not  expect  to 'stop 
the  pollutions  entirely  in  every  case  before  marriage  but 
we  can  reduce  them  to  normal  limits.  We  can  assure  Ihese 
patients  that  it  is  perfectly  normal  for  a  continent  man  to 
have  a  pollution  once  in  ten  days  to  two  weeks.  The  prog-  • 
nosis  in  urethrorrhea  is  likewise  very  good  under  proper 
treatment.  Diurnal  pollutions  are  much  more  obstinate 
than  the  nocturnal  variety,  but  finally  yield  to  persistent 


132  Disorders  of  the  Sexual  Function. 


treatment.  Defecation  spermatorrhea  is  a  much  more  seri- 
ous condition  than  the  forms  previously  mentioned,  and 
urination  spermatorrhea  is  the  worst  of  all.  Defecation 
spermatorrhea  which  is  only  present  on  severe  strammg, 
or  after  the  passing  of  hard  fecal  masses,  is  hardly  more 
important  than  nocturnal  pollutions,  but  the  variety  which 
comes  with  every  stool,  even  one  watery  in  character,  is 
very  apt  to  be  a  forerunner  of  impotence. 

The  general  prognosis  is  worse  where  there  is  a  heredi- 
tary tendency  to  general  neurasthenia.  It  is  worse  in  cases 
coming  on  after  50  and  accompanied  by  premature  ejacu- 
lation or  total  impotence.  The  condition  represents  extreme 
hyperirritability  of  the  sexual  centers,  and  these  centers  at 
this  age  cannot  stand  much  strain,  and  the  resulting  im- 
potence is  apt  to  become  permanent. 

The  more  excuse  there  is  for  a  pollution,  the  less  serious 
it  is.  Thus,  a  man  who  has  been  continent  for  several 
weeks  is  entitled  to  a  pollution,  and  a  man  who  has  been 
spooning  with  his  girl  for  hours  has  also  a  right  to  expect 
a  pollution  during  the  night.  It  is  only  those  cases  where 
pollutions  occur  with  little  or  no  sexual  excitement,  such 
as  merely  brushing  up  against  a  female  in  a  crowded  car, 
or  merely  thinking  of  one,  which  represent  the  more  serious 

types.  ■      r     1 

In  considering  the  seriousness  in  the  prognosis  of  pol- 
lutions, I  only  refer  to  the  possibility  of  impotence,  and  to 
the  persistence  of  the  general  neurasthenic  symptoms.  Pol- 
lutions, no  matter  how  severe,  never  endanger  life,  and 
there  is  not  the  slightest  evidence  that  they  ever  lead  to 
insanity  or  other  serious  nervous  conditions. 


Pollutions  in  the  Male.  133 

Treatment,  Prophylactic. — Boys  approaching  adolescence 
should  be  told  of  the  probability  of  the  occurrence  of  wet 
dreams  from  time  to  time,  so  that  they  may  not  be  fright- 
ened at  their  appearance  and  run  to  the  first  advertising 
quack  they  hear  about.  It  seems  to  be  the  opinion  among 
young  adults  that  the  appearance  of  a  pollution  is  a  sign 
that  their  sexual  organs  are  ripe  and  demand  their  exercise 
in  coitus.  This  opinion  should  be  very  carefully  warned 
against. 

Every  effort  should  be  made  to  bring  up  the  young  man 
with  as  pure  thoughts  as  possible,  and  to  keep  him  away 
from  suggestive  literature  and  plays.  It  were  well  if  he 
would  abstain  from  alcoholics,  especially  beer,  for  these 
stimulate  the  sexual  centers  as  well  as  the  genitals  them- 
selves. He  should  partake  as  little  of  tea  and  coffee  as 
possible.  Cold  bathing  in  the  morning  should  be  encour- 
aged, but  hot  baths  should  be  taken  as  little  as  possible, 
especially  at  night.  He  should  empty  his  bladder  before 
retiring,  and  arise  as  soon  as  he  awakens,  so  as  to  diminish, 
as  much  as  possible,  the  morning  erection,  which  leads  to 
erotic  thoughts. 

General  Treatment. — The  normal  cases  should  be  told, 
in  plain  and  definite  language,  the  significance  of  pollutions, 
their  harmlessness  if  not  too  frequent,  and  the  measures 
advocated  in  the  prophylactic  treatment  just  mentioned 
should  be  enforced  if  possible. 

In  patients  suffering  from  pathological  pollutions,  the 
measures  just  advocated  under  prophylaxis  must  be  en- 
forced. There  is  little  use  in  treating  these  cases  if  they 
will  not  abstain  from  alcoholics,  tea  and  coffee,   and  all 


Pollutions  in  the  Male.  135 

to  give  a  large  number  of  patients  twenty  minutes  each, 
every  other  day  for  a  long  period.  In  the  few  dispensary 
cases  in  which  I  have  conscientiously  given  it  a  trial,  how- 
ever, I  have  obtained  no  good  results  from  its  use,  but,  as 
stated  above,  the  experiments  have  been  entirely  too  few  to 
warrant  a  decisive  opinion.  Even  the  German  authorities, 
who  have  large  experience  with  this  method,  say  that  some 
cases  are  made  worse  by  it,  and  that  they  cannot  tell  before- 
hand whether  it  will  benefit  or  harm  in  any  particular  case. 
They  also  concede  that,  even  in  cases  where  it  does  good, 
temporary  impotence  often  follows. 

In  defecation  and  urination  spermatorrhea,  the  bro- 
mides do  not  act  as  quickly  or  as  positively  as  in  the  other 
forms.  On  the  theory  (which,  as  heretofore  stated,  has 
not  been  proven  at  all),  namely,  that  the  condition  is  due 
to  a  weakness  of  the  sphincters  of  the  ejaculatory  ducts  and 
of  the  seminal  vesicles,  as  well  as  to  a  weakness  of  the 
musculature  of  the  seminal  vesicles,  I  have  tried  strychnine 
in  small  and  large  doses,  but  without  any  result.  The  main 
treatment  in  these  cases  is  to  avoid  constipation  with  its 
accompanying  straining  at  stool,  the  avoidance  of  the  ac- 
cumulation of  hard  fecal  masses  by  proper  catharsis,  and 
the  treatment  of  the  prostatic  urethra  as  above  indicated. 

In  urethrorrhea  it  is  only  necessary  to  instruct  the  pa- 
tients about  the  harmfulness  of  spooning,  and  their  discon- 
tinuance of  such  and  similar  sexual  excitements  will  gen- 
erally bring  about  a  cure.  If  necessary,  a  few  silver-nitrate 
instillations  in  both  the  anterior  and  posterior  urethra  will 
usually  cure  the  patient. 


136  Disorders  of  the  Sexual  Function. 

POLLUTIONS  IN  THE  FEMALE. 

Pollutions  in  the  female  are  much  less  frequent  than  in 
the  male,  and  also  much  less  understood  than  the  former 
variety.  The  fluid  generally  consists  of  the  secretions  of 
the  Bartholinian  glands.  The  condition  in  virgins  is  gen- 
erally due  to  masturbation  and  in  married  women  either 
to  ungratifying  coitus  (premature  or  rapid  ejaculation  in 
the  male)  or  to  enforced  abstinence  on  account  of  death, 
absence  or  impotence  in  the  husband,  in  the  cases  of  women 
with  pronounced  sexual  passion. 

Just  as  in  the  male,  the  condition  may  be  accompanied 
by  erotic  dreams  which  are  different  in  virgins  than  in 
married  women,  on  account  of  the  difference  in  the  sexual 
experience,*  As  is  v^^ell  known,  there  are  many  erotic  zones 
in  different  parts  of  the  female  anatomy,  the  stimulation  or 
irritation  of  any  of  which  may  give  rise  to  either  libido  or 
pollutions.  Just  as  in  the  male,  these  pollutions  are  the 
result  of  stimulation  of  the  ejaculation  center,  and  the  im- 
pulses may  come  either  from  genitals  or  any  other  erotic 
zone,  or  from  the  cerebrum.  Sometimes  these  pollutions 
are  accompanied  by  the  same  feeling  of  depression  and 
general  nervous  symptoms  as  in  the  male.  The  condition 
is  not  at  all  serious,  and  is  relieved  by  bromides  and  cold 
baths. 


.<« 


M 


CHAPTER  VIII. 
PRIAPISM. 

Definition.  Etiology.  Priapism  in  children.  Priapism  in  adults 
Essential  priapism.  Pathology.  Causes  which  act  upon  the  erection 
center.  Causes  which  act  by  removal  of  inhibition.  Causes  which  act 
directly  upon  the  tissues  of  the  penis.  Symptoms.  Diagnosis.  Course 
and  prognosis.  Treatment.  Clitorism.  Clitoris  crises.  Differenti- 
ation from  pseudo-crises. 

Definition.— Priapism  is  a  persistent  erection  of  the 
penis,  unaccompanied  by  sexual  desire,  and  usually  very 
painful.  Blumi4  defines  it  as  "a  stiffening  or  turgescence 
of  the  male  organ,  which  lasts  longer  than  a  normal  erec- 
tion, and,  instead  of  producing  voluptuous  feelings,  is  often 
accompanied  by  most  unpleasant  sensations  of  pain." 

Etiology.  —The  condition  may  be  brought  on  by  very 
many  different  factors.  \Yt  may  classify  the  etiological 
factors  as  follows: — 

Priapism  in  Children.— Due  to  vesical  calculus,  tight  or 
adherent  prepuce  or  rectal  worms. 

Priapism  in  Adults.~Dne  to  (i)  vesical  or  prostatic 
calculus,  stricture,  cystitis  or  retention  of  urine;  (2) 
gonorrhea,  and  generally  called  chordee;  (3)  ingestion  of 
cantharides;  this  is  at  present  a  very  infrequent  cause;  (4) 
essential  priapism  (a)  due  to  disease  of  the  brain  or 
spinal  cord,  (b)  due  to  injuries  of  the  perineal  region,  (c) 
due  to  alcoholic  or  sexual  excesses,  and  (d)  due  to  leukemia. 
It  should  be  noted  that  some  authorities  limit  the  term 
"priapism"  to  what  has  just  been  described  as  essential 

(137) 


138  Disorders  of  the  Sexual  Function. 


priapism,  and  never  consider  the  other  forms  by  that  name. 
Most  modern  authorities,  however,  understand  by  the  term 
"priapism"  any  abnormally  prolonged  erection  of  the  penis, 
unaccompanied  by  voluptuous  feelings,  irrespective  of  the 
underlying  cause,  and  it  is  under  this  latter  interpretation 
that  the  subject  will  be  discussed  herein. 

Pathology.— The  pathology  varies  with  the  underlying 
etiological  cause.  It  can,  however,  be  roughly  divided  into 
two  classes  as  follows:  (i)  Causes  which  act  upon  the 
erection  center  in  the  spinal  cord,  either  by  direct  irritation, 
by  reflex  action,  or  by  removal  of  inhibition  from  the 
higher  centers.  (2)  Causes  which  act  directly  upon  the 
tissues  of  the  penis,  either  by  interfering  with  its  circu- 
lation or  by  mechanical  infiltration  of  the  tissues  with 
inflammatory  products  or  with  new  growths.  Often  both 
these  factors  come  into  play  at  the  same  time. 

I.  Causes  which  Act  upon  the  Erection  Center  in  the 
Spinal  Cord. — The  center  for  erection  is  situated  in  the 
conus  medullaris,  and  any  lesion  affecting  it  causes  a  loss 
of  erection;  an  irritating  lesion,  however  (a  rare  occur- 
rence), may  temporarily  cause  priapism,  but  paralysis  soon 
follows.  Priapism  mainly  occurs  in  supranuclear  lesions  of 
the  cord.  We  may  classify  the  pathology  under  this  head- 
ing as  follows : — 

{a)   By  direct  irritation  of  the  center. 

{h)   By  reflex  irritation  of  the  center. 

(c)   By    removal    of    the    inhibition    from    the    higher 

centers. 

(a)  Causes  which  act  by  direct  irritation  of  the  erection 
center.     In  certain  cases  of  injury  to  the  spinal  cord,  in 


'^ 


M 


Priapism.  139 

which  the  injury  is  low  down,  the  sexual  center  is  so  irri- 
tated that  it  is  thrown  into  a  state  of  chronic  excitation. 
As  stated  above,  this  is  a  very  infrequent  occurrence  and 
is  of  temporary  duration. 

In  spinal  syphilis  mild  priapism  has  been  observed 
accompanying  inco-ordination  of  the  movements  of  the  legs, 
girdle  pain  and  hyperesthesia  of  the  integument  of  the 
abdomen  and  back,  all  the  symptoms  being  cured  by  anti- 
syphilitic  treatment.^  ^*^ 

In  the  early  and  middle  stages  of  locomotor  ataxia 
priapism  may  occur,  and  cease  in  the  later  stages  of  the 
disease. 

Alcohol  causes  priapism  in  several  ways : — ■ 

1.  Local  irritation  and  through  the  urine. 

2.  Removal  of  the  inhibition  of  a  normal  cortex  of  the 
brain  through  psychic  pathways. 

3.  Changes  in  the  cortex,  but  mainly  subcortex,  due  to 
the  toxic  effects  of  the  alcohol ;  alcoholic  periaxillar  neuritis 
of  the  brain. 

4.  Effects  of  alcohol  upon  the  peripheral  nerves. 

(b)  Causes  which  act  by  reflex  action  on  the  erection 
center.  Under  this  heading  may  be  mentioned  those  cases 
of  priapism  which  are  met  with  in  children  due  to  vesical 
calculus,  tight  or  adherent  prepuce,  and  rectal  worms,  as 
well  as  those  cases  in  adults  due  to  vesical  or  prostatic 
calculus,  stricture,  cystitis,  or  retention  of  urine. 

It  is  well  known  that  even  in  normal  persons  the  dis- 
tention of  the  bladder  during  the  night  causes  an  early 
morning  erection.  It  is  therefore  quite  easy  to  understand 
how  the  constant  irritation  of  the  causes  above  mentioned 


140  Disorders  of  the  Sexual  Function. 

will  bring  about  a  constant  erection,  or,  in  other  words, 
priapism. 

In  priapism  due  to  cantharides  poisoning,  the  intense 
irritation  and  inflammation  of  the  entire  urinary  tract  acts 
in  a  reflex  way,  in  addition  to  the  direct  effect  upon  the 
tissues  in  causing  the  disease. 

(c)  Causes  which  act  by  removal  of  the  inhibition  from 
the  higher  centers.  To  this  class  probably  belong  those  cases 
of  injury  to  the  spinal  cord  high  up  in  the  cervical  region, 
as  well  as  those  occurring  with  cerebral  or  cerebellar  hemor- 
rhage. As  before  stated,  certain  forms  of  priapism  follow- 
ing alcoholic  debauch  come  under  this  heading  also. 

2.  Priapism  due  to  Causes  which  Act  Directly  upon  the 
Tissues  of  the  Penis. — ^Under  this  heading  we  find  the  pri- 
apism due  to  very  widely  different  underlying  causes,  and 
widely  different  pathological  conditions  are  present. 

In  the  first  place  m_ay  be  mentioned  the  priapism  in 
acute  gonorrhea  known  also  as  chordee.  Here  the  con- 
dition is  due  to  an  edematous  infiltration  of  the  corpus 
spongiosum  which  becomes  less  extensible  than  the  corpora 
cavernosa.  When  during  the  night,  due  to  the  heat  of  bed- 
clothes, and  the  reflex  irritation  of  the  acute  inflammation 
present,  erections  occur,  the  corpora  cavernosa  will  erect, 
while  the  corpus  spongiosum  cannot  enlarge.  Thus  the 
penis  is  curved  downward  in  erection  and  the  painful  pri- 
apism or  chordee  results. 

There  is  also  another  form  of  priapism  occurring  in 
acute  gonorrhea  which  is  not  chordee,  as  it  is  not  accom- 
panied by  bending  or  curvature  of  the  penis.  In  these  cases 
the  pathology  is  as  follows:     The  pain  is  due  to  the  fact 


Priapism.  141 

that  the  congested  infihrated  mucous  membrane  and  sub- 
mucous connective  tissue  are  not  able  to  stretch  as  they 
normally  do  when  the  cavernous  bodies  become  engorged 
with  blood.  When  nocturnal  erections  occur,  due  to  similar 
causes  as  those  mentioned  in  connection  with  chordee,  the 
non-elasticity  of  the  urethra  caused  by  this  infiltration  of 
the  mucous  and  submucous  tissue  gives  rise  to  the  intensely 
painful  erections  vvhich  follow. 

Priapism  due  to  alcoholic  and  sexual  debauch  is  due  to 
the  intense  swelling  and  inflammation  found  to  be  present 
not  only  in  the  structures  of  the  penis,  but  also  in  the 
perineal  and  cremasteric  region.  As  a  general  rule,  this 
form  of  priapism  does  not  involve  the  corpora  cavernosa 
and  the  corpus  spongiosum  at  the  same  time.  In  some 
cases  the  glans  penis  and  the  entire  corpus  spongiosum 
have  remained  unaffected,  and  cases  have  been  reported  in 
which  one  corpus  cavernosum  was  intensely  turgescent 
while  its  mate  was  entirely  unaffected. 

Priapism  due  to  cantharides  poisoning  is  due  for  the 
most  part  to  the  intense  inflammation  of  the  urethral 
mucous  membrane  caused  by  the  poison. 

Under  the  present  heading  belong  also  those  cases  due 
to  direct  traumatism  of  the  penis  and  perineum.  Here  the 
extravasation  of  blood  with  its  subsequent  clotting  acts 
mechanically  so  as  to  interfere  with  the  normal  distensibility 
of  the  parts,  thus  causing  the  erections  to  be  painful.  For 
the  same  reason  purulent  infiltrations  of  the  mucous  and 
submucous  tissues  cause  priapism. 

In  cancerous  infiltration  of  the  penile  tissues  the  parts 
become  stiff  and  rigid,  and  thus  mechanically  interfere  with 


142  Disorders  of  the  Sexual  Function. 

the  normal  distensibility  of  erection,  thereby  producing 
priapism. 

In  leukemia,  the  priapism  is  due  to  the  interference  with 
the  return  circulation,  due  to  the  pressure  of  the  enlarged 
glands,  and  also  to  thrombosis  of  the  corpora  cavernosa. 
The  organ  thus  remains  more  or  less  permanently  engorged. 

Symptoms. — The  symptoms  vary  with  the  etiological 
factors.  In  children  there  are  present  only  slight  and  more 
or  less  persistent  erections,  which  are  generally  painless 
and  vanish  with  the  removal  of  the  cause.  The  condition 
can  hardly  be  dignified  by  the  term  priapism,  but  as  it  fits 
in  with  the  definition  of  the  term,  it  has  been  considered  in 
this  connection. 

In  the  adult,  the  cases  of  priapism  which  are  dependent 
upon  reflex  irritation  from  vesical  calculi,  retention,  stric- 
ture, etc.,  are  likewise  very  mild  and  transient  in  character. 
The  body  of  the  organ  is  only  moderately  distended,  and 
except  for  an  uneasy  and  slightly  painful  feeling  in  the 
glans,  little  inconvenience  is  experienced. 

In  the  priapism  caused  by  cantharides  poisoning,  the 
inconvenience  experienced  is  due  in  greater  degree  to  the 
intense  inflammation  of  the  entire  genitourinary  tract  from 
the  kidneys  down,  than  to  the  priapism.  The  symptoms  of 
the  latter,  while  in  some  cases  rather  severe,  are  so  greatly 
overshadowed  by  the  more  dangerous  and  sometimes  fatal 
condition  of  the  other  organs,  as  to  be  entirely  negligible. 

In  the  priapism  which  accompanies  acute  gonorrhea, 
whether  in  the  form  of  chordee  or  not,  the  symptoms  are 
very  pronounced,  and  for  the  time  being  may  eclipse  every 
other  symptom  of  the  disease.     The  attacks  come  on  at 


Priapism.  143 

night,  and  the  intense  pain  awakens  the  patient  from  his 
sleep.  The  entire  organ  is  congested  and  sensitive,  while 
the  pain  is  so  severe  at  times  that  patients  have  tried  to 
break  the  erection  by  direct  force  or  pressure  applied  to 
the  penis,  such  as  a  blow  with  the  wrist  or  from  some 
implement.  The  result  is  disastrous,  as  rupture  of  the 
urethra  may  result.  If  the  attack  subsides,  and  the  patient 
goes  to  sleep  again,  he  is  generally  promptly  awakened  by 
another  attack.  His  sleep  thus  disturbed,  he  becomes  rest- 
less and  awakens  in  the  morning  completely  exhausted. 
For  the  time  being  at  least,  this  is  a  very  serious  compli- 
cation. Cases  are  on  record  in  which  phlebitis  and  gangrene 
has  followed  the  "breaking"  of  a  chordee  by  the  patient, 
and  this  has  finally  resulted  in  death. 

The  priapism  which  depends  upon  injury  to  the  spinal 
cord,  or  upon  cerebral  or  cerebellar  conditions,  is  usually 
not  painful.  This  particular  symptom  is  borne  by  the  pa- 
tient with  but  little  complaint.  There  is  often  no  sexual 
desire,  and  the  only  inconvenience  is  that  caused  by  the 
mechanical  position  of  the  organ.  It  is  probable  that,  in 
comparison  with  the  other  symptoms  of  the  very  serious 
condition  present,  the  former  is  more  or  less  secondary  in 
importance.  This,  however,  is  the  most  persistent  of  all 
the  forms.  Cases  of  continuous  priapism  for  four  or  five 
months  at  a  stretch  have  been  reported,  and  Starr,  in  the 
New  York  Medical  Journal,  June  15,  1887,  reported  a  case 
of  meningomyelitis  in  which  the  patient  suffered  from  mild 
priapism  for  seven  years. 

The  most  painful  forms  of  the  disease  are  met  with  in 
those  cases  where  the  condition  follows  alcoholic  or  sexual 


144:  Disorders  of  the  Sexual  Function. 

excesses.  Here  the  onset  may  be  in  one  of  three  ways. 
Either  after  several  mild  and  frequent  attacks  of  erection, 
lasting  but  a  few  minutes  at  a  time,  a  condition  of  priapism 
finally  sets  in;  or,  after  coitus,  the  penis  refuses  to  go 
down  and  remains  in  a  condition  of  priapism;  or  again 
the  patient  wakes  up  at  night  without  any  premonition,  and 
finds  his  penis  in  a  state  of  painful  erection  which  persists 
for  a  long  time.  Often  the  sufferer  tries  to  relieve  himself 
by  coitus,  but  this  generally  fails  and  makes  matters  worse. 
Even,  in  those  exceptional  cases  where  orgasm  and  emission 
are  possible,  there  is  absolutely  no  pleasurable  feeling 
v/hatever. 

During  the  attack  the  symptoms  are  very  severe,  and 
one  can  do  no  better  than  to  give  Taylor  s^^^  classic  de- 
scription of  the  condition  and  symptoms : — 

"In  its  most  severe  form  the  organ  becomes  m.uch 
enlarged,  tense,  and  comparable  to  cartilage  in  rigidity,  and 
the  seat  of  severe  pain.  The  glans  may  be  double  in  size, 
much  distended,  and  glistening,  as  if  it  would  burst.  The 
corpora  cavernosa  are  very  dense  and  unyielding  to  pres- 
sure in  their  whole  length,  including  their  crura.  The 
corpus  spongiosum  is  likewise  hard  and  swollen,  and  its 
bulbous  expansion  is  in  a  similar  condition.  In  some  cases 
the  perineal  muscles  can  be  felt  as  dense  fibrous  bands,  and 
the  dorsal  vein  of  the  penis  seems  much  distended  and  feels 
like  a  whipcord.  In  many  of  these  cases  attentive  exam- 
ination reveals  very  painful  spots  or  perhaps  nodules  in  the 
corpora  cavernosa,  particularly  toward  their  root  or  in  the 
crura.  Then,  again,  digital  pressure  on  the  bulb  and  over 
the  perineal  muscles  may  cause  an  agony  of  pain.    Spasm  of 


Priapism.  145 

the  cremaster  muscles  may  be  present,  and  the  testes  then 
are  drawn  forcibly  up  to  the  internal  ring.  Redness  and 
swelling  of  the  prepuce  may  be  observed  as  complications. 
As  a  rule  the  integument  of  the  penis  retains  its  normal 
color. 

"In  this  pronounced  condition  the  sufferings  of  the  pa- 
tient are  very  severe,  and  many  authors  apply  the  term 
atrocious  to  the  pain  which  is  seated  in  the  virile  organ. 
The  patients  fear  the  least  touch  of  their  linen  or  of  the 
bedclothes,  and  jarring  of  the  bed  or  heavy  steps  in  the 
room  cause  them  agonizing  suffering.  They  draw  up  their 
legs  upon  the  abdomen  in  order  to  protect  the  penis  from 
the  slightest  touch.  This  organ  may  lie  rigid  against  the 
abdomen,  or  it  may  be  more  or  less  erect  and  at  a  right 
angle  with  the  body  in  the  horizontal  position.  Very  soon 
these  patients  become  much  worried  and  apprehensive,  and 
their  faces  give  evidence  of  anxiety  and  suffering.  In  these 
cases  urination  may  be  accomplished  with  little  difficulty, 
or  the  act  may  be  painful,  slow,  and  halting,  with  a  small, 
sputtering  stream,  or  the  patient  may  have  to  assume  the 
knee-elbow  position  in  order  to  expel  the  urine  from  the 
bladder." 

When  we  consider  that  these  attacks  may  last  for  days 
or  even  weeks  at  a  time,  during  which  little  sleep  is  ob- 
tained, and  that  the  duration  of  the  priapism  with  periods 
of  more  or  less  intermission  may  last  from  three  to  six 
consecutive  weeks  and  even  longer,  and  that  in  one  severe 
case  it  has  lasted  for  a  period  of  five  months,  we  can 
appreciate  that  the  condition  is  really  a  serious  one.  Even 
when,  after  a  long  attack,  relief  comes  at  length,  ever}1;hing 


146  Disorders  of  the  Sexual  Function. 

seems  normal  and  the  patient  is  happy,  this  rehef  in  the 
vast  majority  of  cases  proves  to  be  only  an  intermission, 
and  the  whole  condition  returns  again  in  a  short  time. 
These  remissions  may  come  on  at  rather  long  intervals  and 
are  frequently  brought  on  by  fresh  alcoholic  or  sexual  exces- 
ses. In  some  cases,  however,  exposure  to  cold  or  wet,  or 
severe  bodily  exertion  will  bring  on  a  return  of  all  the 
acute  symptoms. 

It  is  not  every  case,  however,  that  attains  this  severity, 
and  there  are  different  grades  of  suffering  down  to  even 
very  mild  symptoms. 

In  the  priapism  of  leukemic  origin,  all  grades  of  severity 
occur.  Taylor^ ^*^  doubts  the  leukemic  etiology  in  these 
cases,  but  most  other  authorities  have  no  hesitancy  in  stat- 
ing that  the  leukemia  is  the  cause  of  the  priapism. 

Diagnosis. — The  diagnosis  is  made  from  the  local  con- 
dition. We  must  not  be  satisfied,  however,  with  merely 
making  a  diagnosis  of  priapism.  It  is  imperative  to  find  the 
underlying;  etiological  cause  in  order  to  give  the  proper 
treatment.  Thus  to  treat  a  case  of  priapism  in  a  child  or 
adult,  dependent  upon  a  vesical  calculus  or  other  reflex 
condition,  by  means  of  sedative  or  cold  applications  to  the 
erect  penis,  would  be  the  very  height  of  folly.  On  the  other 
hand,  priapism  must  not  be  confused  with  satyriasis,  which 
is  an  entirely  different  condition,  although  the  two  may 
coexist. 

Course  and  Prognosis. — The  prognosis  must  be  guarded, 
as  in  some  cases  gangrene  has  resulted.  Moreover,  in  a 
large  number  of  cases,  impotence  has  been  noted  as  a 
sequela.     The  prognosis  must  be  particularly  guarded  in 


Priapism.  -^^ij 

spinal  and  cerebral  cases,  being  dependent  ypon  the  severity 
of  the  underlying  injury.     In  leukemic  cases,  as  well  as  in 
those  of  sexual  perversion,  the  priapism  is  generally  very 
persistent,  and  even  if  apparently  cured  is  often  followed 
by  relapses.     In  gonorrheal  cases  the  prognosis  is  excellent 
unless  the  patient  does  some  violence  to  his  urethra.     In 
reflex  cases  the  disease  vanishes  with  the  removal  of  the 
cause.    In  traumatic  cases  the  priapism  generally  disappears 
after  a  while,  but  the  trauma  may  have  permanently  injured 
the  urethra.     In  tabes  the  priapism  disappears  as  the  dis- 
ease progresses. 

Treatment.— The  treatment  varies  with  the  etiological 
cause.     In  those  cases  due  to  reflex  irritation  from  vesical 
calculus,   etc.,  common  sense  dictates  the  removal  of  the 
calculus  or  whatever  condition  is  the  origin  of  the  reflex 
Wherever  there  is  a  history  of  syphilis  or  even  a  suspicion 
of  It,  antisyphilitic  treatment  should  be  given.     In  gonor- 
rheal cases  I  have  had  the  best  results  from  opium  and 
belladonna  suppositories,  and  the  local  application  of  ice  to 
relieve  the  erection.     Patients  should  be  especially  warned 
against  any  violent  assault  upon  the  penis  to  reduce  the 
erection.     In  traumatic  cases,  ice  to  limit  the  hemorrhage, 
followed  by  incisions  under  absolute  asepsis  to  remove  any 
blood-clots  and  to  allow  free  drainage  of  the  exudate.    The 
incisions  should  be  made  into  the  most  turgid  portions  of 
the  penis.    Early  incision  is  especially  important  in  purulent 
infiltration. 

For  the  priapism  itself,  especially  for  those  severe  cases 
following  alcoholic  or  sexual  excesses,  morphine,  chloral, 
or  bromide  of  potassium  may  be  used  during  the  paroxysm. 


148  Disorders  of  the  Sexual  Function. 

Either  very  hot  or  very  cold  applications  may  be  employed 
locally,  but  chloroform  narcosis  is  generally  of  nO'  avail, 

CLITORISM  (KLITORISMUS). 

This  is  a  very  infrequent  condition,  and  the  term  has 
not  even  found  its  way  into  English  textbooks  or  other 
works  on  gynecology,  nervous  diseases,  or  sexual  diseases. 
It  cannot  even  be  found  in  medical  dictionaries. 

It  was  first  described  by  Rohleder,  I  believe,  and  is  the 
exact  counterpart  of  priapism.  Indeed,  it  might  be  called 
"priapism  in  the  female."  Rohleder  describes  it  as  a  con- 
dition of  long-continued,  painful,  recurring  erection  of  the 
clitoris.  In  some  cases  ejaculation  takes  place.  It  is  the 
result  of  very  intense  masturbation  or  tribadism.  Hysteria, 
nymphomania,  and  excessive  coitus  are  also  at  times  etio- 
logical factors.  The  treatment  is  that  of  sexual  hyperes- 
thesia, and  the  primary  object  is  the  cure  of  the  Onanism. 

CLITORIS  CRISES. 

Koster'^*'  reported  a  very  rare  condition  of  crisis  in  the 
clitoris,  occurring  in  locomotor  ataxia,  and  similar  to  the 
other  well-known  crises  which  occur  in  this  disease.  The 
few  other  reported  cases  come  mostly  from  French  and 
Italian  writers,  and  up  to  the  case  reported  by  this  writer 
it  was,  I  believe,  unknown  in  Germany. 

The  patient  was  49  years  of  age,  and  had  been  suffering 
from  tabes  for  a  period  of  twenty-one  years.  Besides  the 
condition  presently  to  be  described,  she  also  suffered  from 
laryngeal  crises  and  presented  also  the  classic  symptoms  of 
tabes  dorsalis. 


.  Aijffl 


M 


Clitoris  Crises.  149 


The  crises  came  in  attacks,  which  occurred  every  other 
day,  starting  about  two  days  before  the  menstrual  period, 
and  lasting  during  the  entire  period  and  even  a  few  days 
beyond.  The  nature  of  the  attack  was  as  follows:  The 
patient  experienced  a  peculiar  involuntary  access  of  sexual 
feeling,  a  sensation  of  pleasurable  tickling,  which  began  in 
the  vagina,  travelled  down  the  clitoris  and  vulva,  and  cul- 
minated in  a  true  orgasm  with  spasm  of  the  clitoris  and 
ejaculation.  Immediately  thereafter  sharp,  darting,  lanci- 
nating pains  were  experienced  in  the  vagina,  uterus,  and 
back,  lasting  for  several  hours. 

Like  the  other  crises  of  tabes  they  are  entirely  mdepen- 
dent  of  will,  and  appear  only  at  night  or  when  half-asleep. 
All  efforts  on  the  part  of  the  patient  to  suppress  the  erotic 
feeling  are  generally  without  avail.  Sometimes,  at  the  very 
commencement  of  the  attack,  however,  the  patient  appeared 
to  abort  it  by  getting  out  of  bed  and  walking  about. 

Care  must  be  taken  to  differentiate  these  true  crises  from 
pseudo-crises.  In  the  latter,  owing  to  peripheral  or  radicu- 
lar irritation,  clitoris  crises  may  occur,  especially  during 
light  sleep. 


CHAPTER  IX. 


SATYRIASIS. 


Definition.  Increased  sexual  desire  not  satyriasis.  Etiology. 
Theory  of  von  Krafft-Ebing.  Pathology.  Author's  opinion.  Symp- 
toms. Chronic  satyriasis.  Diagnosis.  Prognosis.  Treatment.  Im- 
portance of  treatment. 

Definition. — Satyriasis  is  defined^^  as  excessive  vene- 
real impulse  in  the  male.  It  is  the  exact  counterpart  of 
nymphomania,  which  is  the  same  condition  in  the  female. 

The  excessive  impulse  must  be  pathological  in  order  to 
constitute  satyriasis.  The  fact  that  a  married  man  (egged 
on  perhaps  by  his  wife)  has  the  desire  and  the  ability  to 
have  intercourse  with  his  wife  very  frequently,  does  not 
constitute  the  disease.  The  amount  of  sexual  intercourse 
a  man  can  have  under  suitable  conditions  varies  normally 
within  very  wide  limits,  and  simply  excessive  coitus  does 
not  constitute  satyriasis.  In  those  afflicted,  there  exists  an 
abnormal,  terrible  desire  or  impulse  to  have  sexual  inter- 
course under  any  circumstances  or  conditions,  irrespective 
of  the  age  of  the  female  or  other  considerations  of  decency 
or  decorum.  As  White  and  Martin^^^  put  it,  "the  sexual 
desire  is  so  overpowering  that  its  gratification  becomes  the 
one  dominant  thought  and  purpose  of  the  patient's  life." 

Etiology.  — The  etiology  is  not  at  all  clear,  and  various 
causes  given  by  some  authors  are  vigorously  denied  by 
others.  This  is  mainly  due  to  the  different  conceptions 
of  the  disease  itself  held  by  different  authorities.  Alcohol- 
ism and  pulmonary  phthisis  are  considered  by  some  as 
(150) 


Satyriasis.  151 

etiological  factors.  Both  continence  and  masturbation  are 
supposed  by  some  to  lead  to  it,  but,  from  a  large  experience 
with  both  of  these  latter  conditions,  I  cannot  at  all  sub- 
scribe to  this  view.  I  have  never  seen  either  a  case  of 
masturbation  or  of  continence  develop  into  satyriasis.  I 
have  also  read  the  reports  of  those  cases  of  supposed  satyr- 
iasis following  continence,  but,  from  an  impartial  reading, 
can  say  that  the  author  had  not  the  correct  conception  of 
the  disease.  One  example  might  be  briefly  given  here.  A 
young  unmarried  clergyman  had  for  many  years  been 
troubled  with  sexual  thoughts  which  he,  however,  success- 
fully repressed.  Finally  his  sexual  feelings  so  overpowered 
him  that  he  became  almost  delirious  and  was  cured  only 
by  regular  sexual  intercourse.  This  case  has  been  frequently 
cited  as  satyriasis  due  to  continence.  To  the  unprejudiced 
mind,  however,  it  is  clear  that  this  was  not  at  all  a  con- 
dition of  satyriasis,  but  simply  an  unusually  powerful  sexual 
desire.  The  very  fact  that  the  patient  was  cured  by  normal 
sexual  intercourse  shows  that  there  was  not  even  a  tendency 
to  the  disease.  As  regards  masturbation  being  a  cause,  we 
must  bear  in  mind  that  the  mere  fact  that  a  victim  of  satyr- 
iasis often  resorts  to  masturbation,  if  he  is  unable  to  satisfy 
his  desire  in  any  other  way,  by  no  means  proves  that  mas- 
turbation is  the  cause  of  the  disease. 

An  interesting  theory  of  the  etioiogy  of  satyriasis  is 
the  atavistic  theory  brought  forward,  I  believe,  for  the  first 
time  by  von  Krafft-Ebing.  In  animals,  especially  during  the 
rutting  season,  the  sexual  instinct  is  so  powerful  as  to 
dominate  all  other  habits  and  render  them  at  this  time 
insensible  to  dangers  ordinarily  carefully  guarded  against. 


152  Disorders  of  the  Sexual  Function. 

As  a  result  of  education  and  breeding  of  many  cen- 
turies, the  sexual  instinct  in  the  normal  human  individual 
has  been  placed  more  or  less  in  the  background,  and  is  not 
"the  predominant  note  in  the  chord  of  human  sentiments, 
but  forms  rather  episodes  in  the  physical  and  psychic  life 
of  cultured  man  with  periods  of  ebb  and  flood.  It  is  rather 
the  generating  element  of  higher  and  nobler  social  and 
moral  sentiments,  leaving  room  for  other  spheres  of  activ- 
ity, whose  object  is  the  furtherance  of  interests  affecting 
the  individual  as  well  as  society  at  large. "^^ 

As  a  result  of  centuries  of  education,  civilized  man  has 
evolved  a  moral  code  for  himself,  which  dictates  that  he 
satisfy  his  sexual  needs  within  certain  limits  of  modesty 
and  morality  and  not,  like  the  brute,  whenever  desire  seizes 
him. 

"Practically  speaking,"^^  says  Krafft-Ebing,  "the  sexual 
instinct  never  develops  in  the  normal,  sane  individual  who 
has  not  been  deprived  by  intoxication  (alcohol,  etc.)  of  his 
reason  or  his  senses,  to  such  an  extent  that  it  dominates 
all  his  thoughts  and  feelings,  to  the  exclusion  of  other  aims 
in  life,  and  tumultuously  and  in  rut-like  fashion  demands 
gratification  without  allowing  the  possibility  of  moral  and 
righteous  counter-presentations,  resolving  itself  into  an  im- 
pulsive, insatiable  succession  of  sexual  indulgences." 

In  satyriasis,  according  to  this  view,  we  have  a  rever- 
sion to  primitive  instincts.  The  patient  becomes,  for  the 
time  being  at  least,  like  the  animal  in  the  rutting  season. 

That  there  may  be  some  truth  in  this  atavistic  theory 
is  shown  by  the  fact  that  among  primitive  peoples  no  re- 
straint whatever  is  imposed  on  the  sexual  impulse;  it  is 


Satyriasis.  I53 

gratified  without  shame  and  without  formahty.  No  hin- 
drance is  offered  to  the  mutual  intercourse  of  the  two 
sexes. 

"While  originally,"  says  Kisch,^^  "savage  and  uncivil- 
ized races,  as  well  as  primitive  man,  made  nakedness  the 
rule  and  cohabitation  was  practised  entirely  unrestrained 
by  law  or  morals,  and  simply  as  an  expression  of  unbridled 
passion,  so  that  complete  promiscuousness  of  sexual  life 
resulted,  civilization  has  set  limits  to  the  sexual  relations 
and  has  introduc-d  marriage  as  a  sacred  institution." 

Lombroso  comments  upon  the  entire  freedom  in  sexual 
relations  among  the  North  American  Indians  and  mentions 
that^^  "periods  of  general  promiscuity  occur  at  certain 
times,  just  as  in  the  case  of  rutting  animals,  probably  in 
the  warm  season  of  the  year,  when  food  is  plentiful.  It  is 
difficuh  to  draw  any  distinction  between  the  noisy  orgies 
of  babboons  and  those  of  the  Australian  negroes,  who  keep 
the  sexes  separate  throughout  the  entire  year,  but  come 
together  like  rutting  animals  at  the  time  of  the  ripening  of 
the  yam." 

Cook^'^  mentions,  in  connection  with  his  first  voyage, 
that  at  Tahiti  he  saw  a  native  in  sexual  intercourse  with  an 
eleven-year-old  girl  before  the  queen,  who  gave  him  direc- 
tions in  that  regard.  The  sexual  act,  according  to  Cook's 
account,  was  the  favorite  topic  of  conversation  between  the 
sexes. 

According    to    Herodotus^^    many    of    the    nations    of' 
antiquity  did  not  keep  the  sexual  relations  private,  but  co- 
habited like  animals  in  any  assemblage. 

Lombroso  and  Ferero,  in  their  work,  "Woman  as  Crim- 


154  Disorders  of  the  Sexual  Function. 

inal  and  Prostitute,"  say  :^^  "In  the  lower  stages  of  develop- 
ment the  sense  of  modesty  is  entirely  absent;  unlimited 
freedom  of  sexual  relation  is  the  general  rule." 

It  might  be  objected,  however,  that  lack  of  modesty  in 
sexual  matters  does  not  constitute  satyriasis.  But,  on  the 
other  hand,  we  can  easily  understand  that  if  such  a  primi- 
tive man  were  to  be  brought  into  contact  with  modern 
society,  it  would  be  impossible  for  him  to  control  his  sexual 
appetite  as  does  the  civilized  man  of  today,  after  centuries 
of  education.  It  is  more  than  likely  that  the  former  would 
have  connection  at  every  opportunity  whenever  the  desire 
seized  him  and  would  be  practically  like  one  afflicted  with 
satyriasis.  In  other  words,  were  a  man  born  today,  with 
prehistoric  or  even  primitive  sexual  instincts,  and  with  that 
lack  of  self-control  which  is  normal  to  primitive  man,  we 
would  certainly  consider  him  suffering  from  satyriasis. 

Pathology. — Opinion  is  divided,  among  those  who  have 
studied  this  condition,  as  to  whether  it  is  a  disease  per  se 
or  only  a  symptom  of  some  form  of  psychosis.  Thus 
Parke^*^  says  that  both  satyriasis  and  nymphomania  are 
more  frequently  symptomatic  of  the  graver  psychosis  depen- 
dent on  derangement  of  cerebral  and  spinal  functions.  On 
the  other  hand,  Wulffen^^^  considers  it  a  pathological  con- 
dition of  sexual  hyperesthesia.  According  to  him,  both 
satyriasis  and  nymphomania  are  not  perversions,  but  simply 
pathological  states.  The  pathological  seat,  in  his  opinion, 
is  to  be  found  in  the  genitals  themselves  and  the  disease  is 
neither  hereditary  nor  are  those  afflicted  degenerates. 
Krafft-Ebing^^  considers  it  a  state  of  physical  hyperesthesia, 
with  a  powerful  participation  of  the  sexual  spheres. 


Satyriasis.  ;j^55 

My  own  opinion  is,  that  in  the  present  state  of  our 
knowledge  (which  is  by  no  means  complete)  it  is  best  to 
consider  satyriasis  as  a  clinical  entity  just  as  we  consider 
impotence,  or  masturbation;  that  is,  a  condition  which  may 
be  due  to  either  local,  cerebral  or  psychic  causes.     This 
conception  does  not  conflict  with  the  opinion  that  the  dis- 
ease is  merely  a  symptom  of  some  graver  psychosis  (psychic 
form),  nor  with  a  case  which  has  come  under  my  own 
observation,  and  which  is  presently  to  be  reported,  where 
the  disease  was  due  to  the  irritation  of  an  exceedingly 
large  and  inflamed  verumontanum,  which  was  seen  through 
the    posterior    endoscope,    and    in    which    the    reduction 
of  the  verumontanum  by  the  application  of  powerful  caus- 
tics eventually  effected  a  cure.     The  view  just  expressed  is 
merely  tentative,  as  it  appears  to  be  the  only  one  to  har- 
monize all  the  clinical  facts.     It  may,  however,  have  to  be 
modified  or  entirely  altered  as  soon  as  more  light  is  thrown 
upon  the  pathology  than  we  know  at  present. 

It  should  be  distinctly  remembered,  in  considering  the 
symptoms  and  history  of  some  of  these  cases,  that  satyriasis 
often  accompanies  severe  forms  of  psychoses,  and  is  to  be 
found  in  connection  with,  and  forms  part  of,  some  forms 
of  insanity. 

Symptoms.  —The  person  afflicted  with  satyriasis  strives 
to  obtain  coitus  at  any  price.  If  he  cannot  obtain  it  in 
the  ordinary  way,  he  sometimes  resorts  to  masturbation  or 
sodomy.  Rape  is  not  uncommon.  WulfTfen^^^  reports  a 
case  of  an  old  man  of  70,  who  married  a  young  girl  with 
whom  he  had  coitus  10,  15  and  20  times  in  twenty-four 
hours,   and   actually  kept  this   up   for  a  period   of  three 


156  Disorders  of  the  Sexual  Function. 

months.  Krafft-Ebing'''^  reports  the  case  of  a  middle-aged 
man  who  left  the  train,  ran  into  a  small  village,  and  raped 
an  old  woman  of  70,  whom  he  found  alone  in  her  home. 
The  case  which  came  under  my  own  observation,  and  above 
referred  to,  was  that  of  a  poor  laborer  who  spent  all  his 
wages  to  obtain  connection,  and  who  told  me  that  he  would 
have  had  connection  several  times  a  day  if  he  had  had  the 
price.  Every  time  he  saw  a  female  he  would  be  seized 
with  an  inordinate  desire,  which  he  found  it  most  difficult 
to  restrain. 

The  entire  psyche  of  these  patients  is  made  up  of  sex- 
uality which  colors  their  entire  world.  Every  thing  they 
see  or  hear  brings  thoughts  on  sexual  matters.  The  phantasy 
produces  sexual  pictures,  and  in  very  bad  cases  there  is  an 
actual  confusion  of  ideas  and  hallucinatory  delirium.  In 
most  cases  of  the  disease,  the  genital  organs  are  in  a  state 
of  continual  turgescence.  Many  of  those  afflicted  event- 
ually find  their  way  into  the  criminal  courts.  "The  sexual 
impulse,"  says  Krafft-Ebing'^^  "may  become  so  strong  as  to 
completely  dominate  both  imagination  and  will  and  to  im- 
peratively demand  relief  in  the  corresponding  sexual  act. 
In  acute  and  severe  cases,  morals  and  will-power  entirely 
lose  their  controlling  influence,  while  in  chronic  and  milder 
cases  restraint  is  still  possible  to  some  degree.  At  the 
acme  of  paroxysm,  hallucinations,  delirium  and  benumbed 
consciousness  appear,  and  often  continue  during  a  prolonged 
period."  These  latter  symptoms,  just  mentioned,  really 
belong  more  to  the  grave  psychoses  than  to  satyriasis 
proper.  He  also  quotes  the  case  of  a  man  in  whom  the 
sexual  impulse  became  so  powerful  that,  if  he  were  absent 


Satyriasis.  157 

from  his  wife  even  for  a  short  time,  he  became  indifferent 
as  to  whether  woman,  man,  or  animal  satisfied  his  desire. 

There  is  also  a  form  of  chronic  satyriasis  which  is 
described  by  Krafft-Ebing^^  as  follows:  "To  this  class  be- 
long men  who  suffer  from  sexual  neuresthenia  as  a  result 
of  abusus  veneris,  and  particularly  of  masturbation,  and 
who  at  the  same  time  possess  intense  libido  sexualis.  Their 
imagination,  just  as  in  acute  cases,  is  intensely  excited,  their 
mind  is  full  of  obscene  pictures,  so  that  even  the  most  sub- 
lime things  they  contemplate  are  tainted  with  lustful  images 
and  suggestions.  All  the  thoughts  and  desires  of  such  men 
are  concentrated  on  sexuality,  and,  as  the  flesh  is  weak,  they 
gradually  acquire  the  grossest  perversions  of  the  sexual 
act,  under  the  stimulus  of  their  imagination." 

Diagnosis. — The  diagnosis  is  to  be  made  from  a  careful 
study  of  the  history  of  each  case.  It  is  especially  important 
to  make  the  correct  diagnosis  and  differential  diagnosis  in 
criminal  cases,  so  as  to  fix  the  responsibility  in  cases  of 
rape  or  other  criminal  assaults. 

Prognosis. — In  the  absence  of  a  distinct  pathological 
condition  the  prognosis  as  to  cure  is  bad.  Many  of  the 
milder  cases,  however,  seem  to  be  able  to  control  them- 
selves to  a  certain  degree,  often  even  to  a  very  marked 
degree,  and  they  may  go  through  life  without  getting  them- 
selves into  trouble. 

Treatment. — In  each  and  every  case,  it  is  well  to  inves- 
tigate the  condition  of  the  posterior  urethra.  In  the  case 
reported  by  me  above,  I  found  a  definite  pathological  con- 
dition, the  removal  of  which  cured  the  disease.  The  patho- 
logical condition  in  that  particular  case  was  an  extremely 


158  Disorders  of  the  Sexual  Function. 

enlarged  and  congested  verumontanum,  the  largest  I  had 
ever  seen,  and  the  treatment  consisted  in  direct  application 
of  very  strong  silver  nitrate  to  the  parts  through  the  Wos- 
sidlo-Goldsmith  posterior  urethroscope.  Why  a  diseased 
verumontanum  should  have  caused  satyriasis  in  that  particu- 
lar case,  and  why  in  hundreds  of  other  cases  which  I  have 
seen  practically  the  same  condition  in  the  posterior  urethra 
should  have  had  no  such  effect,  is  one  of  the  unsolved 
mysteries  of  sexual  neuroses.  Both  Forel  and  v.  Schrenck- 
Notzing  report  cases  relieved,  and  in  some  cases  cured,  by 
the  use  of  hypnotism.  In  these  they  considered  mastur- 
bation to  be  the  underlying  cause. 

Even  though  we  cannot  get  at  the  etiological  factors, 
or  remove  the  underlying  pathological  condition  (especially 
in  the  psychic  and  cerebral  forms),  we  must  not  neglect 
treatment  nevertheless.  We  must  positively  interdict  alco- 
holics, as  well  as  coffee  and  tea.  We  must  also  remove  any 
local  genital  condition  as  well  as  anything  that  psychically 
stimulates  the  sexual  centers.  The  reason  for  this  treat- 
ment is  as  follows :  There  are  very  many  mild  cases  of 
satyriasis,  in  which  the  patient  under  ordinary  circumstances 
is  quite  able  to  control  himself,  but  if  drunk,  or  under  ad- 
ditional outside  sexual  stimulation,  is  entirely  unable  to  do 
so,  and  gets  himself  into  serious  trouble.  The  more  severe 
cases  ought  to  be  placed  in  an  institution,  for  the  protection 
of  society  as  well  as  for  their  own  protection,  and  we  ought 
not  to  wait  until  some  unfortunate,  uncontrollable  impulse 
brings  them  into  the  criminal  courts. 


m 


CHAPTER  X. 

NYTvIPHOMANIA. 

Definition.  General  considerations.  'Etiology.  Heredity.  Pathol- 
ogy.  Symptoms.  Illustrative  cases.  Xymphomania  and  sterility. 
Diagnosis.     Course   and  prognosis.     Treatment. 

Definition. — Xymphomania  may  be  defined  as  excessive 
venereal  impulse  in  the  female.  As  has  already  been  men- 
tioned, it  is  the  exact  counterpart  of  satyriasis,  and  the  two 
conditions  are  generally  considered  together. 

It  is  commonly  asserted  that,  while  satyriasis  is  rather 
rare,  nymphomania  is  not  at  all  uncommon,  and  is  certainly 
much  more  frequently  met  with  than  satyriasis.  I  cannot, 
however,  subscribe  to  this  comparision  of  the  frequency  of 
the  two  conditions.  The  error  has  been  made,  I  believe,  in 
not  taking  into  account  the  normal  sexual  desire  of  woman. 
AA'hen  a  single  man  has  sexual  desire  he  generally  indulges 
in  intercourse,  and  no  notice  is  taken  of  the  fact.  But, 
under  our  present  social  conditions,  an  unmarried  woman 
is  supposed  to  suppress  all  thoughts  of  sexual  intercourse, 
and  so  we  have  come  to  regard  one  who,  teased  by  a 
strong  (though  still  normal)  sexual  impulse,  betrays  it  by 
her  actions  as  a  njTnphomaniac.  This  condition,  however, 
is  not  true  n}'mphomania.  In  making  our  comparisons  of 
the  frequency  of  nymphomania  as  compared  to  satyriasis, 
we  must  take  into  accoimt  that  the  sufferer  from  satyriasis 
may  remain  undetected  for  a  long  time  fin  mild  cases 
possibly  for  life)  while  the  minphomaniac  is  more  readily 
recognized. 

(159) 


160  Disorders  of  the  Sexual  Function. 

Etiology. — Much  that  has  been  said  concerning  the 
etiology  of  satyriasis  also  applies  to  nymphomania.  Neither 
culture  nor  breeding  seem  at  times  to  have  any  etiological 
influence.  It  is  found  in  the  most  cultured,  in  the  most 
modest,  and  in  the  most  religious,  almost  to  the  same 
degree  as  in  those  less  carefully  educated.  As  with  saty- 
riasis, while  many  of  the  nymphomaniacs  are  given  to  mas- 
turbation, from  this  fact  alone  we  cannot  conclude  that 
masturbation  was  the  cause  of  the  nymphomania. 

One  factor,  however,  stands  out  prominently  in  the 
etiology  of  these  cases,  and  that  is  the  hereditary  factor. 
In  so  many  cases  of  nymphomania  we  find  an  immediate 
history  of  insanity  or  other  severe  psychosis  in  one  or  the 
other  of  the  parents,  or  very  near  relatives,  that  we  cannot 
help  coming  to  the  conclusion  that  nymphomania,  far  more 
than  satyriasis,  is,  in  the  vast  majority  of  cases,  really  a 
psychopathy.  Another  fact  worthy  of  mention  is  that  so 
many  nymphomaniacs  end  up  in  insane  asylums.  In  this 
connection,  however,  we  must  take  into  consideration  that 
nymphomania  may  be  but  a  symptom  of  some  graver  form 
of  psychosis,  and  it  may  well  be  that,  in  some  cases  at 
least,  it  is  among  the  first  symptoms  of  insanity.  As  far 
as  our  present  knowledge  goes,  no  known  factor  (outside 
of  heredity)  will  cause  nymphomania.  In  other  words, 
the  nymphomaniac  is  horn,  and  not  made. 

Pathology. — As  may  be  gathered  from  a  consideration 
of  the  etiology,  the  pathology  is  not  at  all  understood.  We 
do  know,  however,  that  the  disease  is  not  dependent  upon 
any  local  condition  of  the  genitals,  and  all  we  can  say  at 
present  is  that  the  disease  probably  has  its  seat  in  the  brain. 


Nymphomania.  161 


Symptoms. — In  nymphomania  the  sexual  desire  is  purely 
physical  in  character,  and  centered  upon  the  local  pleasur- 
able excitement  of  the  genitals.  There  is  none  of  the 
higher  feeling  of  love  which  is  so  characteristic  of  the 
erotomaniac. 

The  best  and  most  careful  rearing  of  girls  suffering 
from  nymphomania,  says  Reti,i24  cannot  save  them  from 
their  downfall.  In  their  wild  passion,  casting  all  moral 
and  social  considerations  aside,  they  throw  themselves  into 
the  arms  of  sin.  The  more  they  abandon  themselves  to  the 
gratification  of  their  lust,  the  greater  is  the  desire  of  their 
morbidly  irritated  sexual  centers  for  lecherous  satisfaction. 
Every  indulgence  increases  the  desire  and  lessens  the 
capacity. 

Trelat^24  ^^j^g  q£  ^  yo^ng  girl,  the  daughter  of  a  pro- 
fessor, who  at  the  age  of  15  would  receive  soldiers  at 
night  through  her  bedroom-window  to  satisfy  her  increased 
desire. 

Talmeyi24  cites  the  following  case  from  Reti:  The  pa- 
tient lived  happily  with  her  husband  until  after  the  birth 
of  her  first  child.  From  that  moment  insatiable  lust  seized 
her.  An  irresistible  craving  suddenly  took  hold  of  her— 
an  indomitable  lust  to  embrace  a  man.  In  her  genitals  she 
felt  a  morbid  itching,  an  inexplicable  excitement,  a  burn- 
ing desire  for  sexual  gratification.  In  the  beginning  her 
husband  tried  to  satisfy  her  until  he  discovered  his  impos- 
sibility to  do  this.  She  did  not  allow  an  hour  of  the  day 
to  pass  without  demanding  gratification  from  her  husband. 
He  was  terrified  to  see  her  pressing  her  genitals  to  the 
edge  of  the  table,  to  the  door  or  any  other  hard  object,  in 


11 


162  Disorders  of  the  Sexual  Function. 

order  to  satisfy  her  sensual  appetite.  AVhen  she  became 
worse  from  day  to  day  her  husband  decided  that  she  was 
ill  and  brought  her  to  the  hospital  for  examination.  At 
the  introduction  of  the  speculum,  at  first  a  morbid  contrac- 
tion of  the  constrictor  cunni  muscle  occurred.  The  touch 
of  the  carunculse  myrtiformes  provoked  intense  pain.  After 
surmounting  the  obstacle,  however,  the  pain  ceased  and  a 
blissful  rapture  ensued.  "Now!  Now!"  exclaimed  the  pa- 
tient when  the  entire  speculum  was  w^ithin  the  vagina.  A 
convulsive  movement  seized  her  entire  body,  a  thrill  went 
through  her,  and  she  made  all  the  movements  of  a  pas- 
sionate coition. 

The  nymphomaniac  tries,  by  all  sorts  of  coquetry  and 
exposure  of  her  genitals  if  necessary,  to  attract  men  to 
her  for  purposes  of  coitus.  In  many  cases,  the  mere  sight 
of  a  man  is  enough  to  throw  her  into  the  most  intense 
sexual  excitement.  Wulffen^^^  gives  the  following  instance 
from  Merzbach :  A  Berlin  lady,  belonging  to  the  highest 
society,  grabbed,  under  cover  of  her  napkin,  at  the  dinner, 
the  genital  organs  of  her  supper  partner. 

One  of  the  prominent  symptoms,  especially  in  young 
girls,  is  the  demand  for  gynecological  examination,  and 
especially  for  catheterization.  Any  excuse  for  examination 
is  brought  forward.  The  patients  will  voluntarily  retain 
their  urine  in  order  to  have  to  be  catheterized.  The  mind 
of  these  patients  is  simply  full  of  sexual  ideas.  The  pa- 
tient, if  unmarried,  will  invent  numberless  diseases  for  the 
purpose  of  being  manipulated  by  the  gynecologist. 

Krafift-Ebing'''^  rightly  says  that  the  milder  cases  of 
nymphomania  claim  our  sympathy  not  less  than  those  un- 


^ 


Nymphomania.  163 


fortunate  women  who  by  irresistible  impulses  are  forced 
to  sacrifice  feminine  honor  and  dignity,  for  they  are  fully 
conscious  of  their  painful  situation;  they  are  a  toy  in  the 
grip  of  morbid  imagination  which  revolves  solely  around 
sexual  ideas  and  grasps  even  the  most  distant  points  in  the 
sense  of  an  aphrodisiac. 

Many  of  these  cases,  in  their  despair,  come  begging  for 
castration,  in  the  hope  of  finding  relief  in  this  operation, 
and  some  have  even  attempted  suicide. 

According  to  Herodotus,  the  pyramid  of  Cheops  was 
built  by  the  numerous  lovers  of  the  daughter  of  this  king, 
who  raised  this  enormous  monument  in  recognition  of  the 
innumerable  times  she  had  yielded  herself  to  their  desires. 

Lombroso^'^  cites  several  examples  of  this  inordinate 
sexual  desire  as  follows :  One  w^oman  surrendered  herself 
to  her  husband's  laborers;  another  had  for  her  lovers  all 
the  desperadoes  of  Texas;  a  third  had  intercourse  with  all 
the  herdsmen  of  her  village;  a  fourth,  though  her  husband 
occupied  a  good  social  position,  led  the  life  of  a  prosti- 
tute; a  fifth,  a  cultured  and  intelligent  woman,  entertained 
a  common  bricklayer,  etc.  He  also  gives  the  following 
examxples:  A  hysterical  girl  visited  a  physician  and  said 
to  him,  "I  am  still  a  virgin ;  take  me."  She  submitted  him 
to  the  utmost  extremity  of  provocation,  and  asserted  after- 
ward that  she  had  been  violated.  A  rich  young  lady  met 
a  workingman  in  the  street,  offered  herself  to  him,  was 
accepted,  and  when  she  returned  home  related  the  affair 
with  laughter.  White  and  Martin^^^  mention  the  case  of 
a  mother  of  five  children  who,  in  despair  about  her  inor- 
dinate sexual  desire,  attempted  suicide,  and  then  sought  an 


164  Disorders  of  the  Sexual  Function. 

asylum.  There  her  condition  improved  but  she  never 
trusted  herself  to  leave  it. 

Prostitution  is  often  the  logical  outcome  of  nympho- 
mania. 

Rohleder^^^  has  called  attention  to  the  fact  that  nym- 
phomaniacs are  not  infrequently  sterile.  From  a  theoreti- 
cal standpoint  this  might  appear  very  odd,  but  Rohleder 
gives  the  following  reasons  for  the  sterility  in  these  cases : — 

1.  On  account  of  the  frequent  and  promiscuous  coitus, 
they  very  often  become  infected  with  gonorrhea,  with  its 
resulting  sequelae, 

2.  Even  if  not  infected  with  gonorrhea,  the  frequenth'- 
repeatfed  acts  of  coitus  result  in  inflammations  of  the  vagina 
and  uterus,  which  predisposes  to  sterility. 

3.  There  results  a  weakness  or  partial  paralysis  of  the 
vaginal  walls  and  its  musculature,  with  the  result  that  the 
spermatozoa  rapidly  flow  out  of  the  vagina  after  coitus. 

4.  On  account  of  the  rapid  orgasm  and  the  violent, 
stormy  coitus,  the  spermatozoa  are  quickly  expelled  during 
coitus. 

Diagnosis. — The  diagnosis  is  made  from  a  careful  con- 
sideration of  the  entire  history.  We  must  remember  that 
simple  increase  of  sexual  desire  does  not  constitute  nym- 
phomania, and  that  the  dividing  line  between  normal  and 
pathological  sexual  desire  is  not  easily  defined.  Whenever 
a  single  girl  seeks  or  enjoys  gynecological  examination,  or, 
without  evident  cause,  desires  catheterization,  we  must  sus- 
pect nymphomania. 

Course  and  Prognosis. — The  course  of  the  disease  is 
generally  from  bad  to  worse,  and  the  prognosis  is  generally 


Nymphomania.  165 


very  bad.     ]\Iany  of  these  cases  end  up  as  prostitutes,  and 
quite  a  few  become  insane. 

Treatment. — The  treatment  is  very  unsatisfactory,  as  in 
the  vast  majority  of  cases  nothing  can  be  done  for  them. 
According  to  Forel,  ^^loll,  von  Schrenck-Notzing,  and 
Fuchs,  hypnotism  has  cured  mild  cases,  but  has  been  found 
absolutely  powerless  in  the  severe  forms  of  the  disease. 
Forel  especially  \varns  against  the  method  of  treatment  by 
marrying  a  nymphomaniac  with  a  man  who  is  the  victim 
of  satyriasis.  This  has  been  tried,  with  the  result  that  the 
children  inherited  the  sum  total  of  the  degenerate  qualities 
of  the  parents.  Rohleder^''-''  states  that  Frankel  has  been 
trying  Roentgen  treatment  of  the  ovaries,  with  the  idea  of 
not  only  causing  sterility  but  also  a  diminution  of  the 
libido,  but  he  does  not  know  if  any  good  has  resulted 
therefrom.  The  best  that  can  be  done  for  these  unfortu- 
nates is  to  put  them  into  an  asylum  where  they  can  be  of 
no  harm  either  to  themselves  or  to  society  in  general. 


CHAPTER  XI. 
FRIGIDITY. 

Definition.  Total,  partial,  congential,  acquired.  Frequency  of  con- 
dition. Frigidity  different  from  lack  of  orgasm.  Etiology  and  pathol- 
ogy. Normal  frigidity.  Acquired  frigidity.  Intellectual  frigidity.  Con- 
genital frigidity.  Heredity.  Pathology.  Frigidity  and  sterility.  Author's 
discussion  on  sexual  passion.  Symptoms.  External  characteristics  of 
frigid  women.  Diagnosis.  Prognosis.  Treatment.  Necessity  of  in- 
structing husband. 

Definition. — In  direct  contrast  with  the  intense  desire 
for  coitus  which  we  have  just  described  as  characteristic  of 
the  nymphomaniac,  we  have  the  woman  afflicted  with  frigid- 
ity. Here  there  is  an  absence  of  any  incHnation  to  sexual 
intercourse.  Frigidity,  then,  may  be  defined  as  a  lack  of 
sexual  desire  in  the  female.  It  is  often  described  as  anes- 
thesia sexualis. 

Frigidity  may  be  total  or  partial,  congenital  or  acquired. 
In  total  frigidity  the  patient  has  absolutely  no  desire,  some- 
times even  a  feeling  of  disgust  for  the  sexual  act.  In 
partial  frigidity  there  may  still  be  some  feeling  left,  but 
it  is  present  to  but  a  very  slight  degree,  and  only  on  infre- 
quent occasions.  While  total  frigidity  is  rare,  partial  frigid- 
ity is  not  at  all  uncommon.  At  least  lo^  of  all  married 
women  suffer  from  partial  frigidity,  and  some  authorities 
have  placed  it  as  high  as  40%. 

Frigidity  must  not  be  confused  with  that  condition  in 
which,  during  sexual  intercourse,  the  orgasm  fails  to  occur. 
Although  this  latter  condition  may  be  associated  with  fri- 
gidity and  may  lead  to  that  condition,  yet  it  is  not  frigidity, 
(166) 


Frigidity.  16  Y 

although  very  often  described  as  such  by  some  authors. 
By  frigidity  we  mean  a  condition  where  there  is  a  lack  or 
total  absence  of  sexual  desire.  There  are  very  many 
women,  however,  who  have  normal  or  even  very  intense  sex- 
ual desire,  but,  on  account  of  some  pathological  condition, 
cannot  have  an  orgasm  during  coitus.  This  condition  may 
be  compared  to  that  form  of  impotence  in  the  male  in  which 
the  desire  is  normal,  and  erection  may  even  occur,  but  the 
organ  goes  down  either  before  or  just  after  intromission, 
and  neither  ejaculation  nor  orgasm  takes  place. 

Etiology. — Frigidity  is  normal  before  puberty  and  in 
old  age.  It  may  also  be  considered  normal  in  modestly 
reared  girls  up  to  their  marriage,  and  it  is  not  abnormal 
to  have  it  persist  for  some  time  after  marriage.  As  a 
matter  of  fact  the  pleasurable  sexual  sense  is  very  often  not 
developed  until  some  time  after  marriage,  and  after  many 
acts  of  coitus.  The  adage,  "The  girl  has  to  be  kissed  into 
a  woman,"  is  undoubtedly  true  in  many  cases.  Frigidity 
is  also  normal  for  a  short  time  after  a  normal  sexual 
intercourse.  It  may  be  acquired  or  congenital,  and  these 
will  be  considered  separately. 

Acquired  Form. — Frigidity  may  be  caused  by  a  lack  of 
relationship  between  the  male  and  female  genitalia.  Thus, 
a  very  large  or  roomy  vagina,  with  an  undersized  penis  in 
the  male,  or  even  a  markedly  relaxed  condition  of  the 
vaginal  musculature,  or  any  other  similar  condition  which 
does  not  allow  of  intimate  contact  of  the  penis  with  the 
vagina  may  be  the  cause.  Marked  lacerations  after  child- 
birth often  result  in  the  same  condition.  Impotence  or 
rapid  ejaculation  in  the  male  may  also  be  the  cause  of 


168  Disorders  of  the  Sexual  Function. 

frigidity  in  the  female.  This  latter  condition  is  especially 
operative  if  present  at  the  very  commencement  of  married 
life,  before  the  sexual  sense  has  been  developed  in  the 
female.  Such  ^vomen  may  go  through  their  entire  life 
without  ever  knowing  what  sexual  pleasure  is.  In  some 
cases  it  has  happened  that  such  a  woman  in  her  second 
marriage  becomes  perfectly  normal.  Coitus  interruptus, 
especially  if  started  right  after  marriage,  may  cause  fri- 
gidity, for  the  same  reason. 

Masturbation,  especially  if  it  has  been  practised  for  a 
long  while  before  marriage,  may  be  the  cause  of  frigidity. 
Castration,  especially  if  performed  before  puberty,  will  al- 
most necessarily  lead  to  frigidity.  Various  psychic  or 
temperamental  conditions,  such  as  lack  of  affection  between 
the  parties,  fear  of  pregnancy,  etc.,  are  sometimes  etiologi- 
cal causes.  Faulty  methods  of  education,  in  which  the 
sexual  elements  have  been  unduly  repressed,  are  stated  by 
some  authorities  as  causing  frigidity.  There  can  be  no 
question  that  the  method  of  education  of  girls,  in  which 
they  are  supposed  to  suppress  all  sexual  feeling,  and  are 
supposed  to  remain  in  ignorance  of  everything  sexual,  has 
a  marked  tendency  toward  the  development  of  frigidity. 
Should  such  a  girl  marry  for  purely  social  reasons,  it 
would  not  be  surprising  if  her  exceedingly  dormant  sexual 
centers  should  continue  to  remain  dormant  after  marriage, 
and  never  be  aroused  from  their  lethargy  by  a  mate  en- 
tirely unsuited  to  her. 

Intellectual  frigidity,  according  to  Sturgis^^^  is  that 
condition  where  a  w^oman's  thoughts  seldom  or  never  turn 
to  thoughts  of  love,  but  are  given  to  intellectual  studies,  to 


Frigidity.  169 

scientific  pursuits,  and  who,  in  fact,  represses,  consciously 
,  or  unconsciously  as  the  case  may  be,  all  sexual  thoughts 
or  desires;  indeed,  they  never  enter  her  mind,  and  she 
regards  that  portion  of  her  nature  as  beneath  contempt, 
and  considers  the  menstrual  function  in  no  other  light  than 
that  of  a  nuisance.  Sturgis  rightly  considers  this  condi- 
tion, in  the  majority  of  cases,  more  apparent  than  real, 
and  feels  that  if  such  a  woman  were  to  meet  her  right 
intellectual  mate,  her  frigidity  would  vanish. 

Congenital  Form. — In  many  cases,  no  etiological  factor 
can  be  found,  the  female  simply  being  born  with  little  or 
no  sexual  desire.  From  a  study  of  the  sexual  passion  in 
many  women,  I  have  found  that  there  is  a  large  heredi- 
tary element  about  it.  Thus,  I  have  very  often  seen  an 
entire  family,  all  the  members  of  which,  both  male  and 
female,  were  very  passionate  sexually,  and  others  again 
where  the  opposite  condition  prevailed.  What  applies  to 
families  also  applies  in  a  larger  sense  to  races.  As  is  well 
known,  there  are  certain  races,  especially  the  negro,  and, 
in  general,  the  Southern  races,  who  have  the  sexual  pas- 
sion markedly  developed,  while  the  Northern  races,  as  a 
rule,  are  much  less  passionate. 

Pathology. — The  pathology  varies  with  the  etiological 
cause.  In  lacerations  after  childbirth,  which  cause  a  re- 
laxation of  the  vaginal  walls,  thus  making  the  vagina  too 
roomy  for  the  penis,  and  preventing  the  intimate  contact 
of  penis  with  vagina  during  coitus,  the  pathology  is  obvious. 

Contrary  to  what  one  might  possibly  expect,  injuries 
and  diseases  of  the  clitoris  rarely,  if  ever,  lead  to  frigidity. 
Cases  of  rudimentary  clitoris,  cases  where  the  clitoris  has 


170  Disorders  of  the  Sexual  Function. 

been  bound  down  by  adhesions  so  that  it  could  not  pos- 
sibly come  in  contact  with  the  male  organ  during  coitus, 
and  even  rare  cases  of  complete  paralysis  of  the  clitoris, 
in  which  all  sensation  has  been  abolished,  have  been  seen 
more  or  less  frequently,  and  yet  in  none  of  these  cases  has 
there  been  the  slightest  effect  produced  upon  the  woman's 
desire.  On  the  other  hand,  injuries  to  the  vaginae  bulbi, 
as  well  as  injuries  to  the  constrictor  cunni,  have  caused 
frigidity. 

In  chronic  masturbation  the  pathology  is  as  follows: 
As  a  result  of  the  frequent  irritation  and  stimulation  of 
the  external  genitals,  these  parts  have  become  very  sensi- 
tive, in  fact  much  more  sensitive  than  the  interior  of  the 
vagina.  As  a  result  also  of  the  oft-repeated  act,  the  sexual 
centers  have  at  first  been  rendered  irritable,  and  then  more 
or  less  exhausted,  so  that  stronger  and  stronger  external 
stimuli  are  necessary  to  arouse  them.  When  such  a  person 
marries,  the  ordinary  friction  or  stimulation  of  coitus  is 
not  sufficient  to  arouse  them,  and  they  derive  no  pleasure 
from  the  act  and  become  frigid. 

In  inverts,  who  sometimes  marry  for  economic  or  other 
reasons,  frigidity  is  the  rule.  Here  the  pathology  consists 
in  the  psychic  makeup  of  the  individual.  Having  only 
sexual  feeling  for  one  of  their  own  sex  (for  they  are 
really  males  with  female  genitalia),  frigidity  must  follow 
as  a  matter  of  course. 

In  frigidity  due  to  impotence  In  the  male,  the  pathology 
must  be  sought  in  the  sexual  centers.  These  very  often  lie 
dormant  in  the  unmarried  female,  and  have  to  be  aroused 
into  action  after  marriage.     Should  the  male  be  unable  to 


Frigidity.  171 

arouse  them,  they  continue  in  their  dormant  condition,  and 
frigidity  finally  results. 

In  total  frigidity,  the  sexual  center  is  absolutely  unable 
to  be  stimulated  either  by  psychic  or  organic  sexual  stimu- 
lation. In  partial  frigidity,  the  sexual  center  is  capable  of 
stimulation,  but  with  difficulty. 

Frigidity  is  very  often  part  of  a  symptom-complex, 
consisting  of  infantile  uterus,  scanty  and  delayed  menstrual 
function,  sterility  and  lack  of  sexual  passion.  In  these 
cases  there  seems  to  be  a  lack  of  development  of  the  entire 
sexual  makeup,  anatomical,  physiological,  and  psychical. 
In  this  connection  I  investigated,  several  years  ago,  the 
relationship  of  sexual  passion  to  sterility  and  for  this  pur- 
pose interrogated  289  sterile  women.  My  method  of  pro- 
cedure and  the  results  obtained  have  been  set  forth  in  a 
previous  work^^  of  mine,  from  which  I  quote  the 
following : — 

The  subject  of  sexual  passion  is  one  about  which  it  is 
very  difficult  to  obtain  any  accurate  scientific  information. 
In  most  of  my  cases  I  interviewed  only  the  wife  and  ob- 
tained my  information  from  her.  It  is  a  very  difficult 
matter  at  any  time  to  decide  what  constitutes  normal  sex- 
ual desire,  and  when  it  is  to  be  considered  increased  or 
diminished.  It  is  still  more  difficult  when  we  have  to  take 
the  patient's  statement  what  he  or  she  thinks  is  normal  or 
increased  or  diminished  sexual  desire.  Thus  it  is  not  at  all 
uncommon  for  a  man  to  tell  you  that  his  sexual  ability  is 
below  par,  because  he  has  heard  of  a  friend  who  can 
indulge  in  coitus  several  times  a  night,  whereas  he  only  in- 
dulges as  many  times  a  week.     Again,  the  sexual  passion 


1Y2  Disorders  of  the  Sexual  Function. 

largely  depends  upon  the  sexual  passion  of  the  partner.  Thus 
a  man  with  average  sexual  desire  would  not  have  much  inter- 
course or  as  much  sexual  intercourse  if  his  wife  were  very- 
frigid  or  suffered  from  dyspareunia;  whereas,  if  he  had  a 
wife  who  was  very  passionate  and  constantly  fondling  him, 
he  would  naturally  have  increased  desire  and  perform  the 
act  more  frequently.  Again,  most  of  my  female  patients 
were  married  but  once,  and  never  had  connection  with  any- 
one except  their  own  husbands,  and  so  had  no  standard  to 
go  by  whether  their  own  or  their  husbands'  desire  was 
increased  or  diminished.  Some  women  also  do  not  care 
to  admit  that  they  have  increased  sexual  desire,  although 
the  majority,  thinking  that  it  is  important  for  the  treat- 
ment (and  in  their  desire  to  have  children  they  will  an- 
swer any  question,  no  matter  how  delicate),  will  freely  tell 
you  what  they  consider  the  truth.  It  must  be  remembered 
that  people  judge  largely  by  comparison.  So  a  man  with 
a  very  marked  sexual  desire,  having  for  wife  a  woman  with 
normal  sexual  desire,  is  likely  to  consider  that  his  passion 
is  normal  and  that  his  wife's  passion  is  below  normal,  and 
so  forth. 

Fully  realizing  all  these  difficulties,  I  have,  nevertheless, 
attempted  to  gather  some  facts  upon  this  very  important 
subject,  and  have  tried,  as  far  as  possible,  to  avoid  many 
of  the  errors  above  mentioned,  and  to  which  such  statistics 
are  especially  liable.  While  a  few  of  the  authors  mentioned 
in  the  bibliography  state  in  a  general  way  what  their  im- 
pression is  regarding  the  relationship  of  sexual  desire  to 
sterility,  I  believe  this  is  the  first  attempt  to  collect  actual 
data  on  the  subject,  as  I  have  come  across  no  regular  sta- 


Frigidity.  173 

tistics,  even  in  the  voluminous  work  of  Kisch.^  I  wish  to 
state,  also,  that  these  facts,  although  collected  almost  en- 
tirely from  dispensary  patients,  were  not  collected  in  the 
dispensary,  where  one  has  obviously  not  the  time  to  go  into 
such  details.  All  my  work  on  this  subject  was  done  in  my 
own  private  office,  where  I  saw  the  patients  not  once,  but 
dozens  of  times  in  some  cases,  and  where  the  patients,  after 
seeing  that  I  took  a  real  interest  in  them,  were  perfectly 
willing  to  answer  frankly  and  truthfully  all  my  questions. 
I  desire  to  repeat  that,  if  questioned  with  proper  tact  and 
dignity,  no  sterility  patient  will  refuse  to  answer  to  what, 
under  ordinary  circumstances,  would  be  considered  embar- 
rassing questions.  I  make  this  statement  advisedly,  because 
I  know  that  all  the  answers  to  my  questions  were  tjuthful, 
as  far  as  the  patients  were  able  to  speak  on  the  subject. 

The  statistics  given  here  are  the  result  of  a  very  careful 
investigation  of  the  sexual  history  of  289  cases.  As  I  could 
find  no  authority  to  go  by,  nor  any  standard  as  to  what 
may  be  called  normal,  diminished  or  increased  sexual  desire, 
I  made  up  the  following  rules  and  have  been  guided 
accordingly : — 

In  the  first  place,  I  determine  how  many  times  on  the 
average,  except  during  the  menses,  sexual  intercourse  took 
place  a  week.  As  most  people  apply  for  relief  for  sterility 
at  least  a  year  after  marriage,  and  in  most  cases  after  the 
second  or  third  year,  the  novelty  of  sexual  intercourse  has 


1 A  few  years  after  my  work  was  published,  Rohleder^^^"  in  1914 
published  the  4th  volume  of  his  work  in  which  he  quotes  some  statis- 
tics on  this  very  subject  collected  by  Duncan  more  than  thirty  years 
ago.  Duncan  found,  in  191  sterile  women,  20.4%  with  lack  of  sexual 
passion. 


174  Disorders  of  the  Sexual  Function. 

already  worn  away.  Then  I  carefully  inquired  which  of 
the  parties  (or  if  both)  desired  the  connection.  In  most 
of  the  cases  the  wife  will  tell  you  that  it  is  the  husband 
who  asks  for  it;  but  further  inquiry  often  brings  out  the 
fact  that  the  wife  has  the  desire,  but  does  not  care  to  ask 
her  husband  to  have  connection  with  her.  I  then  ascer- 
tained the  fact  whether  the  wife  cares  for  intercourse  at 
all  or  only  submits  to  please  her  husband.  In  those  cases 
where  the  wife  does  not  care  for  intercourse,  I  am  careful 
to  determine  whether  the  frigidity  is  due  to  pain  during 
the  act.  In  several  cases  where  coitus  was  frequently 
indulged  in,  I  discovered  that  this  was  not  due  to  increased 
sexual  desire,  but  to  the  fact  that  the  couple  thought  they 
stood  a  better  chance  of  having  a  child.  If  the  man  is 
questioned,  I  ascertain  whether  he  thinks  his  wife  is  more 
or  less  passionate  than  women  with  whom  he  may  have 
had  intercourse  before  marriage.  If  it  is  the  wife's  second 
husband,  I  inquire  if  he  is  more  or  less  passionate  than 
the  first  one  was.  It  must  be  stated  that  any  one  of  these 
questions  taken  by  itself  may  not  mean  very  much,  but  if 
we  take  them  all  together  we  can  fairly  make  up  our  minds 
as  to  the  sexual  passion  of  each  party.  Furthermore,  in 
my  statistics  I  have  considered  the  sexual  passion  dimin- 
ished if  (outside  of  the  menstrual  period)  sexual  inter- 
course was  indulged  in  less  than  once  a  week  on  the 
average,  and  increased,  if  performed  more  than  four  times 
a  week.  These  facts  were,  of  course,  taken  into  account 
with  all  the  other  facts  enumerated  above  in  making  up  the 
statistics.  My  data  then  finally  show  that  in  289  investi- 
gations the  sexual  passion  was  as  follows : 


^ 


Frigidity.  175 

Husband.  Wife. 

Normal    43.0%  35.2% 

Increased    46.5%  20.7% 

Diminished  10.4%  44.1% 

We  thus  see  that  in  almost  half  the  cases  the  woman's 
sexual  desire  is  diminished.  While  we  all  know  that  in 
even  non-sterile  families  the  woman  is,  as  a  general  thing, 
not  as  passionate  as  the  man,  the  above  data  are  sufficient 
to  show  that  in  sterile  women  the  sexual  passion  is  cer- 
tainly much  less  than  normal. 

Symptoms.  — The  frigid  woman  has  little  or  no  inclina- 
tion for  sexual  intercourse,  and  receives  no  pleasure  from 
the  act.  Very  often  these  women  submit  as  a  sense  of 
duty  to  their  husbands,  they  may  give  birth  to  one  or  more 
children,  and  very  often  are  ideal  mothers,  and,  except  for 
the  frigidity,  ideal  wives.  Some  of  the  more  intelligent 
may  even  simulate  sexual  passion  to  please  and  deceive 
their  husbands.  The  congenital  sufferers  never  seek  the 
physician's  advice,  but  the  husband  seeks  the  physician, 
complaining  of  his  wife's  coldness,  and  on  interrogating 
the  wife  we  find  that  she  has  derived  no  pleasure  from  the 
act. 

Some  women,  on  the  other  hand,  seem  proud  of  their 
frigidity,  and  boast  about  what  they  consider  their  superior 
will  and  control  of  their  desire.  Some  unmarried  women, 
unless  for  economic  reasons  they  take  up  prostitution,  easily 
remain  virtuous ;  they  may  not  marry  and  brag  about  their 
chastity  and  the  fact  that  no  man  can  conquer  them.  "Even 
among  married  women,"  says  Napheys,  "there  are  wives 
who  pride  themselves  on  repugnance  or  distaste  for  their 


176  Disorders  of  the  Sexual  Function. 

conjugal  obligations.  They  speak  of  their  coldness  and 
the  calmness  of  their  senses  as  though  they  were  not  de- 
fects. Yet  the  sour,  shallow,  sexless  shrew  is,  as  Jordan 
justly  says,  an  imposture  as  wife,  and  her  marriage  is  a 
fraud."i24 

There  is  on  record  an  extreme  case  of  frigidity,  in 
which  the  wife  read  novels  while  her  husband  was  having 
sexual  intercourse  with  her,  so  little  was  she  interested  in 
the  act.  Although  the  mojority  of  such  cases  cannot  be 
recognized  by  any  external  sign,  appearance  or  mannerism, 
yet  in  some  cases  there  is  certainly  a  less  feminine  and  a 
more  masculine  character  about  the  person.  Many  of  these 
women  make  excellent  executive  chiefs,  and  do  not  pos- 
sess the  instability  which  is  so  characteristic  of  women. 
They  are  very  mannish  in  their  manners,  are  exceedingly 
practical,  have  strong  will-power,  but  are  by  no  means 
inverts.  As  already  stated,  they  often  make  excellent  wives 
and  resign  themselves  without  complaint  to  the  sexual  em- 
braces of  their  husbands,  although  the  act  has  nothing  but 
repugnance  for  them. 

Diagnosis. — The  diagnosis  is  generally  made  from  the 
history,  which  we  as  a  rule  obtain  from  the  husband.  In 
the  unmarried,  the  diagnosis  can  only  be  suspected,  but  is 
rarely  sought  for. 

Prognosis. — The  prognosis  depends  upon  the  possibility 
of  the  removal  of  the  etiological  cause.  In  total  congenital 
frigidity,  the  prognosis  is  generally  bad,  but,  apart  from 
the  frigidity,  there  are  no  evil  consequences  of  the  con- 
dition. The  patient  never  knew  what  sexual  excitement  or 
desire  was,  and  therefore  never  misses  it. 


^W^^i^i-^ 


% 


Frigidity.  177 

Treatment. — The  treatment  varies  with  the  etiological 
cause.  Lacerations  or  other  gynecological  conditions  should 
be  remedied  if  possible.  Masturbation  should  receive  the 
appropriate  treatment  outlined  in  the  article  under  that 
heading. 

Of  great  importance,  because  so  much  good  can  be 
done,  is  the  management  of  those  cases  of  frigidity  where 
the  sexual  centers  have  not  been  duly  aroused  on  account 
of  the  husband.  Although  I  have  already  gone  into  this 
subject  somewhat  heretofore  (see  page  53),  it  is  of  such 
vital  importance  that  I  may  be  pardoned  for  speaking  about 
it  again  here. 

The  tendency  of  late  has  been  to  see  to  it  that  the 
young  female  should  know  more  of  sexual  matters  before 
her  marriage  than  has  been  the  rule  heretofore.  This  is 
perfectly  proper.  It  seems  to  be  taken  for  granted,  however, 
that  no  such  instruction  is  necessary  for  the  male.  It  is 
taken  for  granted  that  most  men  have  indulged  in  sexual 
intercourse  before  their  marriage,  and  therefore  do  not 
need  instruction  in  this  regard. 

Even  taking  it  for  granted  that  most  men  have  visited 
prostitutes  before  marriage,  it  cannot  be  too  strongly  em- 
phasized that  there  is  all  the  difference  in  the  world  between 
connection  with  a  prostitute  and  with  one's  wife,  and  that 
such  a  man  still  needs  enlightenment  upon  many  points  in 
sexual  matters. 

When  a  man  goes  to  a  prostitute  he  has  but  one  object 

in  view,   and  that  is  the  gratification  of  his  own  sexual 

desire.     The  sexual  desire  or  gratification  of  his  partner 

has  no  concern  for  him.     Moreover,  if  his  sexual  partner 

12 


1T8  Disorders  of  the  Sexual  Function. 

should  prove  frigid,  he  simply  selects  some  one  else  on  the 
next  occasion. 

When  a  man  enters  matrimony,  however,  he  should 
understand  that  the  marriage  certificate  is  not  merely  a 
legal  license  to  indulge  in  sexual  intercourse  whenever  he 
desires.  He  should  understand  that  his  mate  has  the  poten- 
tiality of  a  keen  sexual  appetite,  which  it  is  his  privilege 
to  arouse  and  maintain.  He  should  not  cease  being  the 
courtier  the  moment  the  object  of  his  love  is  bound  to  him. 

For  this  reason,  the  marriage  bed  should  be  the  scene 
of  the  most  tender  caresses,  and  all  the  artifices  of  love 
should  be  brought  into  play  in  order  to  awaken  in  the 
female  the  sexual  desire.  The  act  of  coitus  should  be  but 
the  final  stage  of  this  love-making.  The  first  intercourse 
should  never  consist  of  a  licensed  rape.  The  husband 
should  be  taught  to  restrain  his  passion  until  his  spouse  is 
fully  awakened  and  ready  to  respond  to  his  sexual  advances. 

As  a  matter  of  fact,  most  married  men  only  think  of 
themselves  in  this  regard.  If  they  have  desire,  they  at 
once  have  intercourse,  although  the  wife  may  be  half- 
asleep.  By  the  time  he  is  through  she  is  just  beginning  to 
become  excited,  and  then  he  withdraws  his  penis,  little 
caring  for  the  condition  of  nervous,  unsatisfied  sexual  desire 
in  which  he  leaves  his  wife. 

For  this  reason,  before  he  proceeds  to  intercourse,  he 
should,  with  the  most  tender  caresses  and  all  the  artifices  of 
love,  awaken  in  her  the  passion  and  desire  for  intercourse, 
and  then,  and  not  till  then,  should  he  proceed  to  the  act.  If, 
as  is  often  the  case,  his  orgasm  should  come  before  that 
of  his  wife,  he  should  not  remove  his  penis,  but  should 


Frigidity.  1Y9 

allow  it  to  remain  in  the  vagina,  at  the  same  time,  with 
kisses  and  caresses,  fan  his  wife's  excitement  until  she  has 
had  her  orgasm.  His  wife  will  then  appreciate  that  she  is 
not  merely  his  licensed  prostitute,  but  his  wife.  Among 
the  lower  animals  the  male  jumps  on  the  female  when 
desire  seizes  him,  and  in  some  cases  nature  has  provided 
him  with  spines,  which  project  from  his  penis  during  erec- 
tion, and  insert  themselves  into  the  vagina,  so  that  the 
female  cannot  get  away  before  his  coitus  is  completed. 
Nature  has  not  provided  man  with  such  an  apparatus,  but 
has  given  him  intelligence  instead,  and  it  is  for  him  to 
employ  that  intelligence,  rather  than  brute  force,  in  his 
sexual  relations.  Were  married  men  properly  instructed  in 
this  regard,  there  would  be  less  complaint  about  the  coldness 
of  their  wives,  and  less  complaint  from  the  wives  that  sex- 
ual intercourse  brings  nothing  to  them  but  pregnancy. 

For  the  congenital  frigidity,  Rohleder^^'  suggests  the 
internal  administration  of  yohimbin,  which  is  supposed  to 
act  by  determining  an  increase  of  blood  to  the  genitals,  just 
as  in  the  male,  and  this  erection-like  action  may  start  or 
increase  the  sexual  desire.  He  also  recommends  coitus  dur- 
ing the  menstrual  period,  as  in  even  extreme  cases  of  fri- 
gidity there  is  some  sexual  excitement  present  at  this  time. 

In  the  absolutely  hopeless  cases  it  would  be  proper,  for 
the  peace  of  the  family,  to  instruct  the  wife  to  simulate 
sexual  excitement,  including  orgasm.  There  is  certainly  no 
harm  in  this  fraud,  if  it  answers  the  purpose,  and  it  is 
certainly  far  better  than  the  breaking  up  of  a  family  by 
divorce,  or  the  leading  of  the  man  into  extramarital  coitus, 
with  all  its  dangerous  consequences. 


CHAPTER  XII. 
VAGINISMUS. 

Definition.  Etiology.  Pathology.  Symptoms.  Penis  captivus. 
Illustrative  cases.  Diagnosis.  Course  and  prognosis.  Vaginismus 
and  the  law.  Prophylactic  treatment.  General  treatment.  Dilatation. 
Operation. 

Definition. — Vaginismus  may  be  briefly  described  as  a 
violent,  painful  spasm  of  the  muscles  surrounding  the 
vaginal  entrance.  It  was  first  described  by  Dr.  Marion 
Sims,  and  I  can  do  no  better  than  to  give  his  classic  de- 
scription of  the  disease,  as  quoted  by  Howard  Kelly^^ : — 

"By  the  term  'vaginismus'  I  mean  an  excessive  hyper- 
esthesia of  the  hymen  and  vulvar  outlet,  associated  with 
such  involuntary  spasmodic  contractions  of  the  sphincter 
vaginae  as  to  prevent  coition.  This  irritable  spasmodic  ac- 
tion is  produced  by  the  gentlest  touch;  often  the  touch  of 
a  camel's  hair  brush  will  produce  such  agony  as  to  cause 
the  patient  to  shriek,  complaining  at  the  same  time  that  the 
pain  is  that  of  thrusting  a  knife  into  the  senstive  part.  In 
a  very  large  majority  of  cases  the  pain  and  spasm  conjoined 
are  so  great  as  to  preclude  the  possibility  of  sexual  inter- 
course. In  some  instances  it  will  be  borne  occasionally, 
notwithstanding  the  intolerable  sufifering,  while  in  others  it 
is  wholly  abandoned,  even  after  the  act  has  been  repeat- 
edly, as  it  were,  perfectly  performed." 

Etiology.  — Although  in  the  vast  majority  of  cases  a 
definite  pathological  condition  will  be  found,  it  is  also  im- 
portant to  remember  that,  as  a  general  thing,  there  exists 
(180) 


Vaginismus.  181 


at  the  same  time  an  underlying  neurotic  condition  as  a 
predisposition  to  the  condition.  In  no  other  manner  than 
this  can  we  explain  the  well-known  fact  that  vaginismus 
is  very  rare  among  the  poor,  and  that  most  of  the  cases 
are  met  with  in  the  overcultured,  highly  nervous-tensioned 
women.  In  other  words,  although  as  a  general  thing  the 
disease  is  brought  on  by  a  definite  genital  trauma  or  other 
definite  pathological  condition  in  the  genitals,  exactly  the 
same  local  condition  would  not  cause  vaginismus  unless 
there  were  a  predisposing  underlying  nervous  condition 
present. 

Pathology. — While  we  are  wont  to  regard  vaginismus 
as  a  neurosis,  still  I  believe  careful  investigation  will  very 
often  show  some  local  or  general  condition  present  to 
account  for  the  reflex  spasm.  It  is  very  important  to 
remember  this,  so  that  we  may  not  fall  into  the  error  of 
treating  it  as  a  disease  per  se.  It  is  really  only  a  symptom, 
and  we  should  be  unremitting  in  our  search  for  the  under- 
lying cause. 

One  of  the  most  frequent  underlying  causes  is  the  awk- 
ward attempt  at  coitus  by  the  male  at  the  very  commence- 
ment of  married  life.  These  awkward  attempts,  often 
combined  with  a  peculiar  formation  of  the  vulva  and 
vagina,  sometimes  cause  the  penis  to  enter  the  extreme  upper 
portion  of  the  vagina,  and  to  press  the  urethra  against  the 
symphysis  pubis;  the  severe  pain  which  results  causes  the 
woman  to  shrink  from  and  fear  every  act  of  coitus,  and  is 
also  the  cause  of  the  reflex  spasms  of  the  muscles  of  the 
vaginal  outlet.  Very  often,  the  first  attempts  at  coitus  cause 
unusually  severe  lacerations  and  fissures  which  provoke  the 


182  Disorders  of  the  Sexual  Function. 

spasms  of  the  muscles  at  each  succeeding  attempt.  Cases 
have  been  recorded  where,  during  coitus,  the  penis  has 
entered  the  urethra.  In  other  cases  coitus  has  been  carried 
on  per  rectum,  without  the  male  being  aware  of  the  fact. 
Sometimes  it  has  been  discovered  after  many  years  of  mar- 
ried life  that  the  penis  had  never  entered  the  vagina  at  all, 
but  had  simply  rubbed  up  against  the  external  genitals, 
without  either  party  knowing  the  difference. 

In  many  cases  the  pathological  condition  present  is  a 
very  tough  hymen,  and  it  is  the  ineffectual  attempts  upon 
it  which  produce  the  involuntary  muscular  spasms.  In 
other  cases  still,  the  carrunculae  myrtiformes  are  found  to  be 
exquisitely  tender  and  inflamed,  while  in  another  class  per- 
sistent search  has  brought  out  the  fact  that  a  urethral  car- 
uncle was  responsible.  Sometimes  nothing  but  a  hyper- 
esthesia of  the  vaginal  mucous  membrane  is  found  upon 
examination. 

A  penis  which  is  too  large  is  often  assigned  by  the  wife 
as  the  cause.  But  this  condition  is  really  one  of  very  great 
rarity,  and  we  ought  not  to  give  much  credence  to  such 
explanation.  Other  pathological  conditions  sometimes 
found  are :  neuroma  of  the  fossa  navicularis ;  varicose  veins 
or  prolapse  of  the  urethral  mucous  membrane;  fissures  of 
the  fourchette,  neck  of  the  bladder,  or  anus;  masturbation 
or  any  other  cause  likely  to  increase  the  irritibility  of  the 
external  genitals. 

Symptoms.  — Vaginismus  is  most  frequently  met  with  in 
young  women  at  the  commencement  of  their  married  life. 
At  the  first  attempts  at  coitus,  the  musculature  of  the 
vaginal  entrance  is  thrown  into  a  violent  involuntary  pain- 


Vaginismus.  183 

fill  spasm,  which  effectually  prevents  the  entrance  of  the 
penis.  Generally  the  spasm  involves  only  the  muscles  of 
the  vaginal  entrance,  but  in  severe  cases  the  entire  muscu- 
lature of  the  perineum,  anus,  and  bladder  seem  to  partici- 
pate. In  rare  cases  the  constitutional  effects  are  so  severe 
that  general  convulsions  have  followed.  With  each  renewed 
attempt  the  spasm  seems  to  increase  and,  after  a  while,  in 
some  cases  the  mere  approach  of  the  male,  or  even  the  men- 
tion or  memory  of  the  act,  is  enough  to  throw  the  parts 
into  a  spasm. 

As  a  result,  such  women  dread  the  attempt  at  coitus, 
and  shrink  from  the  act,  although,  in  some  cases,  they  have 
borne  this  condition  for  a  long  time  from  a  sense  of  duty. 
Often  modesty  restrains  them  from  seeking  medical  aid, 
until  finally  a  nervous  breakdown  ensues. 

Although  the  penis  is  generally  prevented  from  enter- 
ing, it  does  enter  in  some  cases,  but  with  difficulty  and 
with  pain.  As  a  general  thing  the  spasm  comes  on  with 
the  first  approach  of  the  male  organ,  but  in  some  cases  it 
does  not  commence  until  the  male  organ  has  entered  and 
then  ensues  the  peculiar  condition  known  as  penis  captivus, 
in  which  the  penis  is  caught  inside  the  vagina,  is  held  there 
by  the  muscular  spasm,  and  cannot  be  withdrawn.  The 
greater  the  attempt  of  the  male  to  extricate  himself,  the 
more  severe  the  spasm  becomes,  while  the  interference  with 
the  return  flow  of  the  blood  in  the  male  organ  causes  it  to 
enlarge  still  more,  thus  materially  increasing  the  difficulty. 
In  particularly  severe  cases  it  has  been  necessary  to  chloro- 
form the  female  in  order  to  release  the  penis  from  the 
vaginal  spasm.     A  case  of  such  undue  severity  is  reported 


184  Disorders  of  the  Sexual  Function. 

by  Davis*^^  as  follows :  A  gentleman  entering  his  stable 
found  his  coachman  with  a  maid-servant  in  flagrante  delictu. 
All  endeavors  of  the  pair  thus  surprised  to  separate  proved 
ineffectual,  and  their  attempts  to  draw  apart  caused  intense 
pain  to  both.  Davis,  who  had  been  sent  for,  ordered  an 
ice-douche,  which  failed,  however,  to  liberate  the  im- 
prisoned penis,  nor  was  that  effected  until  the  woman  had 
been  placed  under  chloroform.  The  swollen  and  livid  penis 
exhibited  two  strangulation  furrows,  a  proof  that  two  dis- 
tinct areas  of  the  levator  ani  muscle  had  been  spasmodically 
contracted. 

As  already  stated,  a  gynecological  examination  shows 
the  parts  to  be  extremely  sensitive,  so  that  it  is  sometimes 
impossible  to  insert  the  examining  finger,  and  a  general 
anesthetic  is  needed  for  examination.  This  will  usually  re- 
veal one  of  the  pathological  conditions  mentioned  above. 

Although  vaginismus  is  generally  encountered  in  the  re- 
cently married,  cases  have  occurred  where  it  first  developed 
later  on,  sometimes  even  after  childbirth.  In  some  cases 
the  spasm  came  on  during  labor,  and  interfered  with  the 
birth  of  the  child,  and  it  has  also  been  accidentally  discovered 
upon  gynecological  examination  in  virgins,  the  slightest 
touch  causing  a  muscular  spasm. 

A  particularly  severe  case  is  recorded  by  Sims^-  as  fol- 
lows: A  family  physician  anesthetized  the  wife  for  the 
first  coitus,  which  then  offered  no  difficulty;  he  continued 
to  do  this  at  bi-weekly  intervals  for  a  year,  when  she  be- 
came pregnant  and  bore  a  child  at  term.  The  old  pain 
returned,  however,  and  it  became  necessary  to  resume  the 
"ethereal  relations." 


Vaginismus.  185 


For  obvious  reasons  the  sufferer  from  vaginismus  rarely 
becomes  a  prostitute.  There  exists  a  class  of  women, 
however,  called  by  the  French  "demi-vierges,"  and  by  the 
Germans  "Halbjungfrauen,"  (half -virgins)  who  are  known 
to  permit  anything  sexual  to  be  done  with  them,  except 
the  act  of  cohabitation,  which  they  have  probably  learned 
to  fear  by  reason  of  vaginismus. 

Diagnosis. — Vaginismus  must  be  differentiated  from 
dyspareunia,  although  frequently  a  cause  of  the  latter.  In 
dyspareunia  there  is  only  pain  in  intercourse  and  no  spasm 
of  the  muscles,  while  in  the  vaginismus  the  pain  is  due  to 
the  spasmodic  contractions  of  the  muscles.  In  dyspareunia 
coitus  is  perfectly  possible,  but  only  accompanied  by  severe 
pain  on  the  part  of  the  female,  while  in  vaginismus  coitus 
as  a  general  thing  is  impossible. 

Kraurosis  vulvae,  in  its  early  stages,  may  have  to  be 
differentiated  from  vaginismus.  Careful  inspection,  how- 
ever, even  at  the  commencement  of  kraurosis  vulvae,  will 
reveal  the  sensitive  areas  at  the  ostium  vaginae,  as  well  as 
beginning  shrinkage  of  the  vulvar  integument. 

Course  and  Prognosis. — If  not  treated,  the  disease  goes 
on  from  bad  to  worse,  until  the  entire  nervous  system  suf- 
fers, and  the  patients  literally  become  nervous  wrecks. 
Dyspareunia,  frigidity,  and  sterility  are  the  sequelae.  Mas- 
turbation may  be  the  cause,  but  sometimes  is  the  outcome, 
of  the  disease.  The  prognosis  depends  upon  the  ability  of 
the  surgeon  to  discover  the  underlying  pathological  con- 
dition. If  this  be  found  and  properly  treated,  the  prognosis 
is  excellent. 

The  results  of  treatment,  however,  are  almost  invariably 


186  Disorders  of  the  Sexual  Function. 

gratifying,  though  there  is  a  very  small  percentage  of  cases 
which  resist  all  treatment.  If  pregnancy  ensues,  the  con- 
ditions almost  always  disappear  after  childbirth,  although 
in  very  rare  instances  such  has  not  been  the  case. 

Schmidtmann,  in  his  "Handbuch  der  gerichtlichen  Med- 
izin,  1905,^"^  has  called  attention  to  the  fact  that  on  January 
20,  1893,  the  highest  Austrian  tribunal  handed  down  a 
decision  granting  a  divorce  to  the  husband  in  a  case  where 
the  wife  was  suffering  from  vaginismus  and  refused  to 
undergo  operative  treatment  for  its  cure. 

Treatment,  Prophylactic. — It  sometimes  happens  that  the 
condition  is  accidentally  discovered  in  virgins  upon  gyneco- 
logical examination.  When  this  is  the  case,  marriage  should 
be  absolutel}'-  forbidden  until  the  underlying  pathological 
condition  has  been  discovered  and  removed.  Such  circum- 
stances, however,  should  be  very  rare.  No  virgin  ought  to 
be  examined  unless  a  distinct  indication  presents  itself. 
The  frequent  handling  of  the  virginal  sexual  organs  cannot 
be  too  strongly  deprecated.  In  the  vast  majority  of  cases 
the  treatment  of  vaginismus  can  be  safely  delayed  until 
after  marriage. 

As  a  matter  of  prophylaxis,  it  is  also  necessary  to 
instruct  young  men  before  marriage  to  avoid  any  brutal 
attempts  at  coitus  on  the  wedding  night.  Some  men  actually 
have  the  idea  that  severe  pain  and  hemorrhage  are  essential 
at  the  first  intercourse,  and  believe  in  fact  that  it  is  the 
only  reliable  sign  of  virginity.  According  to  them  most 
any  amount  of  force  is  justifiable,  whereas  it  is  just  at  the 
first  intercourse  that  most  cases  of  vaginismus  start.  Such 
brutal  and  awkward  attempts  cause  severe  lacerations  and 


Vaginismus.  187 


fissures,  while  each  further  attempt  at  coitus  only  aggra- 
vates the  matter. 

Treatment  of  the  Disease. — In  the  first  place  all  attempts 
at  coitus  should  be  positively  interdicted  until  the  condition 
has  been  cured.  In  the  second  place  a  careful  gynecological 
search,  under  anesthesia,  if  necessary,  should  be  made  for 
any  pathological  condition  of  the  genitals,  and  these  con- 
ditions should  receive  appropriate  treatment.  As  above 
stated,  the  fact  cannot  be  too  much  emphasized,  that  in 
vaginismus  there  is  almost  always  present  some  pathologi- 
cal condition  which  may  sometimes  be  very  obscure  and 
apparently  insignificant,  but  which  it  is  our  bounden  duty 
to  search  out  and  treat.  Any  other  method  of  dealing  with 
vaginismus,  purely  as  a  disease  per  se,  will  bei  doomed  to 
absolute  failure. 

After  removal  of  the  cause,  we  have  next  to  treat  the 
condition  of  spasm,  which  often  remains  as  a  pure  neu- 
rosis, sometimes  due  to  fear,  even  after  the  underlying 
cause  has  been  eliminated. 

In  mild  cases,  before  attempting  coitus,  a  pledget  of 
cotton  soaked  with  5^,  of  cocaine  sol.  should  be  inserted 
into  the  vagina  for  a  few  minutes,  and  the  vulvar  region 
should  also  be  painted  with  a  similar  solution.  This  is  a  very 
excellent  method,  although  Rohleder^*^'''  especially  warns 
against  it  for  the  following  reason :  He  claims  that  it  may 
happen  that  the  anesthetic  effect  of  the  cocaine  may  allow 
the  penis  to  enter,  but  that  the  effect  may  wear  off  during 
coitus,  the  spasm  may  return,  and  the  condition  of  penis 
captivus  may  result.  Personally,  I  have  never  seen  such 
consequences  from  the  action  of  cocaine  in  this  condition, 


188  Disorders  of  the  Sexual  Function. 

nor  have  any  of  the  numerous  authorities  whom  I  have 
consulted  ever  reported  such  a  result.  From  purely  theo- 
retical reasoning  I  should  say,  that  once  the  underlying 
cause  has  been  removed,  a  spasm  which  can  be  relieved  by 
cocaine  so  that  the  penis  may  enter  the  vagina  is  not  severe 
enough  to  cause  the  imprisonment  of  the  penis  even  if  it 
does  return.     The  condition  may  be  different,  however,  if 


Vaginal  dilators. 

coitus  can  be  accomplished  simply  through  the  action  of 
the  cocaine  before  the  underlying  pathological  condition  is 
removed. 

In  other  cases,  the  local  hyperesthesia  can  be  relieved 
by  painting  the  affected  parts  twice  a  week  with  a  solution 
of  silver  nitrate,  20  grains  to  the  ounce. 

In  marked  cases,  however,  we  must  resort  to  gradual 
dilatations  of  the  vagina  with  vaginal  dilators.    These  should 


Vaginismus.  189 


be  inserted  in  increasing  sizes,  and  left  in  for  an  hour  at 
a  time.  Later  the  patient  herself  may  insert  them  several 
times  a  day. 

Severe  and  obstinate  cases  require  either  forcible  dilata- 
tions or  incisions.  In  either  of  these  operations  a  general 
anesthetic  is  necessary,  and  it  goes  without  saying  that,  in 
any  procedure  undertaken,  the  hymen  should  be  first  thor- 
oughly removed. 

In  dilatation  the  vaginal  entrance  is  forcibly  stretched 
by  the  operator's  thumbs  until  the  underlying  muscle  is  felt 
to  yield.  A  glass  vaginal  dilator  is  then  inserted,  and  the 
dilatations  are  kept  up  with  the  aid  of  these  dilators  as 
above  described.  At  the  operation  it  is  well  to  stretch  the 
parts  so  thoroughly  that  the  largest  dilator  can  be  inserted. 
It  frequently  takes  several  months  of  constant  dilatation 
to  eliminate  the  spasm  and  permit  the  penis  to  enter.  In 
any  case,  however,  when  pregnancy  has  once  ensued,  the 
condition  generally  vanishes  after  labor. 

The  incision  method,  known  also  as  Hirst's  operation, 
consists  simply  of  making  one  incision  in  the  perineum 
from  the  vaginal  entrance,  half-way  to  the  anus,  and  then 
two  other  incisions  one  and  a  half  inches  long  in  each 
vaginal  sulcus,  which  should  converge  toward  the  medium 
line  and  unite  with  the  perineal  incision.  These  incisions 
should  be  deep  enough  to  divide  the  fascia  and  underlying 
muscular  fibers,  and  should  be  closed  with  catgut  sutures 
and  unite  the  vaginal  to  the  perineal  structures. 

The  operation  has  the  effect  of  lessening  the  contractile 
action  of  the  bulbocavernosi  and  levator  ani  muscles  and 
results  in  a  gaping  of  the  vulvovaginal  orifice. 


CHAPTER  XIII. 


DYSPAREUNIA. 


Definition.  German  conception  of  term.  Etiology  and  pathology. 
Symptoms.  Diagnosis.  Prognosis.  Treatment.  Conditions  akin  to 
dyspareunia.  Dyspareimia  in  the  male.  Definition.  Etiology.  Pa- 
thology.    Symptoms.     Diagnosis.     Prognosis.     Treatment. 

Definition. — Dyspareunia  may  be  defined  as  that  con- 
dition in  the  female  where  coitus  is  accompanied  by  more 
or  less  severe  local  pain. 

Attention  should  be  called  to  the  fact,  however,  that 
the  German  writers,  as  well  as  some  American  writers,  use 
the  word  "dyspareunia"  in  an  entirely  different  sense.  The 
German  writers  define  dyspareunia  as  a  lack  of  sexual 
gratification  on  the  part  of  the  woman  during  coitus.  In 
other  words,  she  has  normal  or  increased  sexual  desire, 
but  never  experiences  pleasure  during  coitus.  This  latter 
condition  must  be  carefully  differentiated  from  frigidity,  in 
which  there  is  an  absence  of  sexual  desire.  The  subject 
will  be  discussed  in  another  chapter.  It  is  important  to 
remember  this  distinction  between  the  German  and  Ameri- 
can conception  of  the  word  "dyspareunia,"  or  else  those 
reading  German  literature  on  the  subject  will  soon  find 
themselves  in  considerable  confusion.  Howard  Kelly,  in 
his  first  edition  of  "Medical  Gynecology,"  as  well  as  the 
translator  of  Kisch's  work  "The  Sexual  Life  of  Woman," 
also  use  the  word  in  the  German  signification. 

Etiology  and  Pathology. — This  condition  is  in  reality 
but  a  symptom  found  in  very  many  different  conditions.  It 
(190) 


Dyspareunia.  191 


may  be  considered  normal  at  the  first  coitus  in  the  female, 
incident  to  the  rupture  of  the  hymen;  nor  should  it  be 
considered  pathological  during  the  first  few  weeks  after 
that  event. 

Among  the  causes  which  induce  dyspareunia  may  be 
mentioned  the  following :  vaginismus;  incomplete,  awkward, 
or  rough  attempts  at  coitus  on  the  part  of  the  male;  hyste- 
ria; local  hyperesthesia;  disproportion  between  the  male  and. 
female  genital  organs;  trauma;  genital  as  well  as  pelvic 
deformity ;  maldevelopment ,  cicatricial  contraction,  or  dis- 
placement of  any  of  the  genital  organs;  inflammatory  con- 
ditions in  the  urethra,  vidva,  vagina,  bladder  or  rectum; 
inflammation  or  infiltration  of  the  pelvic  connective  tissue, 
or  the  peritoneum  covering  the  pelvic  organs;  urethral 
caruncle;  vesical  calculus;  anal  fissure;  pelvic  tumors;  hyper- 
involution;  premature  senility,  etc. 

Symptoms. — As  above  stated,  the  condition  itself  is 
nothing  more  than  a  symptom.  All  we  have  is  simply 
local  or  referred  pain  during  coitus.  But  coitus  is  perfectly 
possible  and  no  muscular  spasm  is  present  unless  the  con- 
dition is  due  to  vaginismus. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of 
the  complaint  of  pain.  It  must  not  be  confused  with  vagi- 
nismus, in  w^hich  coitus  is  generally  impossible,  and  in  which 
the  pain  is  due  to  muscular  spasm. 

Prognosis. — This  depends  upon  the  ability  of  the  surgeon 
to  find  the  underlying  cause  and  to  relieve  it.  Generally, 
the  prognosis  is  good. 

Treatment. — As  in  vaginismus,  we  must  not  treat  the 
condition  as  a  disease  per  se,  but  simply  as  a  symptom  of 


192  Disorders  of  the  Sexual  Function. 

some  pathological  condition.  We  must  make  every  effort 
to  find  the  underlying  cause  and  relieve  it. 

Where  the  condition  is  due  to  rough  or  awkward  coitus, 
full  instruction  should  be  given  both  parties  as  to  the  best 
way  of  conducting  themselves  during  the  act.  The  husband 
should  be  cautioned  not  to  repeat  the  act  too  soon  after  the 
initial  coitus,  so  as  to  give  the  ruptured  hymen  and  other 
lacerations  a  chance  to  heal  up.  He  should  also  be  in- 
structed to  be  gentle  and  to  have  his  organ  well  lubricated 
in  case  difficulty  is  experienced  in  introduction.  The  wife 
also  should  be  instructed  how  to  do  her  utmost  to  assist 
her  husband  in  introducing  the  organ.  As  stated  heretofore, 
it  is  not  uncommon  for  the  husband,  in  his  wild  attempt 
at  coitus,  to  insert  the  penis  everywhere  but  in  the  proper 
place,  and  there  are  cases  on  record  where  coitus  has  taken 
place  in  the  rectum  or  even  urethra,  and  the  hymen  itself 
remained  intact  for  years.  If  necessary,  the  wife  should 
be  given  a  speculum  or  vaginal  dilator  and  shown  how  and 
where  to  introduce  it  herself. 

In  cases  of  marked  spinal  deformity  in  the  female,  in 
which  the  ordinary  posture  of  coitus  is  not  feasible  or  pain- 
ful, it  is  perfectly  justifiable  to  advise  coitus  in  convenient 
positions. 

Where  the  condition  is  due  to  smallness  of  the  vagina, 
it  should  be  treated  by  packing  the  vagina  with  glycerin 
tampons  or  dilating  with  vaginal  dilators,  and,  in  bad  cases, 
by  incisions  similar  to  those  made  in  the  treatment  of  vagi- 
nismus. 

It  may  be  convenient  to  briefly  describe  here  a  condition 
in  the  female  somewhat  similar  to  dyspareunia,  but  of  which 


.M 


Dyspareunia  in  the  Male.  193 

very  little  is  found  in  medical  literature.  In  this  condition 
the  act  of  coitus  is  not  accompanied  by  pain  but  by  other 
disagreeable  sensations. 

Among  these  disagreeable  sensations  which  accompany 
or  follow  shortly  after  coitus  may  be  mentioned  headache, 
nausea,  vomiting,  diarrhea,  abdominal  pains,  vertigo,  flushes, 
paraesthesia,  etc. 

Some  of  these  symptoms  can  be  explained  by  the  Freu- 
dian theory.  This  was  the  case  in  a  young  woman  who, 
when  a  girl,  was  raped.  This  rape  was  accompanied  by 
severe  abdominal  pains,  and  later  on,  when  she  married, 
each  coitus  was  accompanied  by  severe  abdominal  pains. 
The  most  important  point  in  treating  these  cases  is  to  find 
the  local  pathological  condition  which  is  the  cause  of  these 
disagreeable  reflex  sensations.  Where  none  can  be  found 
after  careful  examination,  it  is  advisable  to  send  them  to 
a  competent  neurologist  for  psychoanalysis. 

DYSPAREUNIA  IN  THE  MALE. 

Definition. — Under  this  heading  a  condition  will  be 
described  which,  I  believe,  has  never  been  described  as  a 
clinical  entity,  although  occasionally  mentioned  as  a 
symptom. 

By  dyspareunia  in  the  male,  I  mean  the  exact  counter- 
part of  female  dyspareunia,  namely,  pain  during  coitus. 
Under  this  heading  1  do  not  consider  pain  at  coitus  in  the 
presence  of  acute  inflammation  of  the  urethra,  for  it  is 
obvious  that  if  a  man  is  foolish  enough  to  indulge  in  coitus 
during  an  acute  posterior  urethritis,  prostatic  abscess,  or 
similar  acute  conditions,  the  act  would  be  accompanied  by 

13 


194  Disorders  of  the  Sexual  Function. 

more  or  less  severe  pain.  Such  conditions  are  really  irrita- 
tions of  inflamed  surfaces,  and  under  no  conditions  can 
they  be  considered  as  neuroses,  nor  will  they  be  considered 
under  this  heading. 

Etiology. — So  far  as  my  personal  observation  goes,  I 
have  only  seen  dyspareunia  in  the  male  as  a  sequela  of 
either  masturbation  or  withdrawal,  and  these  two  conditions 
must  therefore  be  considered  the  most  important  if  not  the 
only  etiological  factors. 

Pathology. — The  pathological  seat  is  to  be  sought  for 
in  the  seminal  vesicles  and  ejaculatory  ducts.  Inasmuch  as 
none  of  these  cases  come  to  autopsy,  we  can  judge  the 
pathology  only  by  analogy  and  by  the  result  of  rectal  pal- 
pation of  these  parts. 

Inasmuch  as  the  pleasurable  feeling  of  orgasm  is  the 
result  of  the  squeezing  of  the  seminal  fluid  through  the 
ejaculatory  ducts,  we  can  readily  understand  how  any 
inflammation  of  these  ducts  would  be  accompanied  by  a 
sensation  of  pain,  especially  where  the  inflammation  is  such 
as  would  cause  a  temporary  narrowing  of  part  of  the  lumen 
of  the  duct,  and  so  cause  a  temporary  resistance  to  the  on- 
ward passage  of  the  seminal  fluid. 

Symptoms.  — The  chief  and  only  symptom  complained  of 
by  the  patient  is  a  severe,  acute,  knife-like  pain  coming  on 
just  at  the  orgasm.  It  is  generally  felt  in  the  perineum, 
although  it  may  be  referred  to  the  anterior  urethra,  more 
especially  at  the  meatus.  The  chief  characteristic  of  the 
pain  is  its  simultaneousness  with  the  orgasm  and  its  sharp- 
cutting,  knife-like  character. 

Upon  examination,  we  always  find  the  seminal  vesicles 


Dyspareimia  in  the  Male.  195 


enlarged  and  exquisitely  tender.  The  same  local  conditions 
may  also  be  found  present  in  the  urethra  as  are  found  in 
masturbation  or  withdrawal,  although  the  symptom-com- 
plex may  be  present  in  the  absence  of  every  condition  ex- 
cept the  enlarged  and  tender  seminal  vesicles. 

Diagnosis. — The  diagnosis  is  to  be  made  solely  from 
the  characteristics  of  the  pain  just  described. 

Prognosis. — The  prognosis  is  excellent,  as  every  case 
treated  by  me  so  far  has  absolutely  recovered.  The  cases 
are,  however,  rather  infrequent. 

Treatment. — The  treatment  is  really  the  treatment  of 
the  underlying  condition  and  consists,  briefly,  in  abstinence 
from  sexual  intercourse,  gentle  massage  of  the  prostate 
and  seminal  vesicles,  the  treatment  of  the  accompanying 
congestion  of  the  deep  urethra  by  weak  silver-nitrate  instil- 
lations, the  avoidance  of  alcoholics  as  well  as  tea  and  coffee, 
and,  in  particularly  bad  cases,  the  temporary  administration 
of  bromides.  For  a  detailed  description  of  the  underlying 
conditions,  see  Masturbation  and  Withdrawal. 


CHAPTER  XIV. 

ABSENCE  OF  ORGASM  IN  THE  FEMALE  DURING 

COITUS. 

Definition.  Orgasm  not  synonymous  with  voluptuous  feeling.  Ger- 
man definition.  Etiology.  Pathology.  Physiology  of  normal  coitus 
in  the  female.  Symptoms.  Relationship  to  sterility.  Author's  opinion. 
Diagnosis.     Prognosis.     Treatment. 

Definition. — Under  this  heading  will  be  described  that 
condition  in  which  the  female  has  normal  sexual  desire,  but 
fails  to  experience  any  orgasm  or  other  feeling  of  satis- 
faction during  coitus.  It  must  be  sharply  differentiated 
from  frigidity;  for  in  frigidity  there  is  an  absolute  disin- 
clination toward  sexual  intercourse,  while  in  the  condition 
under  discussion  there  is  normal  or  even  increased  sexual 
desire,  but  the  patient  experiences  absolutely  no  orgasm. 
The  two  conditions  may,  however,  coexist. 

Stress  is  laid  upon  the  point  that  there  is  no  orgasm 
here  during  coitus.  Many  of  these  women  can  provoke 
an  orgasm  by  masturbation  and  many  have  resorted  to  titil- 
lation  of  the  clitoris  during  or  after  coitus  to  bring  it  on, 
but  with  them  the  normal  act  of  coitus  is  insufficient  to 
bring  on  the  orgasm. 

It  should  be  noted  also  that  orgasm  and  voluptuous  feel- 
ing are  not  exactly  synonymous.  The  pleasurable  feeling 
often  begins  at  the  very  commencement  of  coitus,  continuing 
and  increasing  in  force  until  the  orgasm  is  reached.  The 
orgasm  is  the  very  acme  of  the  voluptuous  feeling  and  cor- 
responds with  the  violent  ejaculation  of  the  fluid  from  the 
(196) 


Absence  of  Orgasm  in  Female.  197 

various  glands.  Until  the  orgasm  is  reached  the  woman  is 
in  a  continuous  state  of  excitement,  and  immediately  after 
the  orgasm  there  is  experienced  the  feeling  of  satisfaction. 
Many  of  the  women  suffering  from  the  condition  of  lack 
of  orgasm  during  coitus  experience  more  or  less  intense 
sexual  pleasure  at  coitus,  but  do  not  get  the  relief  which 
orgasm  brings  in  normal  coitus. 

This  condition  has  been  wrongly  described  as  dyspa- 
reunia  by  German  writers  as  well  as  by  some  American 
writers;  but  dyspareunia  is  painful  coitus,  which  is  an  en- 
tirely different  condition.  It  has  also  been  described  under 
the  heading  of  "Impotence  in  the  Female,"  but  while  we 
may  consider  it  as  constituting  one  form  of  impotence  in 
the  female,  it  cannot  be  so  described,  because  there  are 
many  other  forms  of  impotence  in  the  female  as  well. 

Etiology. — Any  condition  which  interferes  with  the  ftill 
completion  of  the  act  of  coitus  may  cause  the  absence  of 
the  orgasm.  Prominent  among  these  causes  may  be  men- 
tioned coitus  interruptus.  Here  the  act  of  coition  is  pur- 
posely interrupted  before  the  climax  is  reached  in  the  male, 
and  naturally  long  before  its  culmination  in  the  female,  with 
the  result  that  in  many  cases  coitus  stops  before  the  orgasm 
can  come  on  in  the  female.  Another  condition  that  acts 
in  a  similar  way  is  impotence  and  rapid  or  premature  ejacu- 
lation in  the  male.  Still  another  cause  may  be  due  to 
awkward  coitus  on  the  part  of  the  male,  especially  where 
much  pain  is  experienced  by  the  female  during  the  act.  In 
the  majority  of  cases  of  rape  no  orgasm  is  experienced.  In 
other  psychic  conditions  such  as  fear  of  impregnation  or 
dislike  for  the  partner,  the  inhibition  from  the  higher  cen- 


198  Disorders  of  the  Sexual  Function. 

ters  may  interfere  with  the  development  of  the  orgasm. 
Masturbation  is  also  at  times  an  etiological  factor,  and  its 
mode  of  action  will  be  presently  described. 

Pathology. — To  clearly  understand  the  pathology  of  the 
condition  under  discussion,  it  is  necessary  to  understand  the 
physiology  of  normal  coitus  in  the  female,  and  the  factors 
which  produce  the  orgasm. 

Briefly  the  physiology  of  normal  coitus  in  the  female 
is  as  follows:  As  soon  as  the  penis  enters  the  vagina,  its 
contact  with  the  sensitive  mucous  membrane  and  its  con- 
tinuous friction  against  this  membrane  starts  a  series  of 
stimuli  which  are  propagated  to  the  optic  thalamus  and  from 
thence  to  the  cerebral  cortex.  This  gives  rise  to  the 
pleasurable  feeling  of  coitus.  At  the  same  time  the  cerebral 
cortex  sends  down  centrifugal  impulses  to  the  erection  and 
ejaculation  centers  in  the  cord.  From  here  other  impulses 
flow  out  to  the  periphery,  with  the  result  that  the  clitoris 
becomes  erect  and  bends  downward  to  meet  the  penis,  the 
entire  genital  apparatus  becomes  filled  with  blood,  the  mus- 
cles go  through  certain  rhythmic  movements,  and  the 
glandular  apparatus  is  also  stimulated  into  action.  At  the 
acme  of  the  sexual  act,  they  spurt  out  their  secretions,  and 
it  is  this  ejaculation  of  the  secretions  of  the  sexual  glands 
(mainly  the  Bartholinian)  at  the  acme  of  the  coital  act 
that  gives  the  extreme  height  of  voluptuous  feeling  which 
constitutes  the  orgasm.  But  the  pleasurable  feeling,  as  al- 
ready stated,  begins  at  the  very  commencement  of  coitus, 
the  orgasm  being  but  its  climax.  With  the  completion  of 
the  orgasm,  and  partly  as  a  result  of  the  ejaculation  and 
the  relaxation  of  the  coital  muscles,  the  compression  of  the 


Absence  of  Orgasm  in  Female.  199 

pelvic  veins  is  released,  the  hyperemia  and  congestion  of 
the  pelvic  organs  disappear,  and  the  parts  soon  regain  their 
normal  condition  of  circulation.  In  the  description  given 
above,  I  have  outlined  only  the  essentials  of  the  physiology 
of  coitus  without  any  pretense  to  completeness,  that  is,  just 
enough  as  is  necessary  for  an  understanding  of  the  pathol- 
ogy of  lack  of  orgasm. 

If,  for  any  of  the  etiological  causes  mentioned,  coitus  is 
interrupted,  the  woman  is  left  in  a  state  of  excitement, 
there  is  no  feeling  of  satisfaction,  and  the  condition  of  her 
nervous  system  may  be  likened  to  that  of  dangling  a  mouse 
before  a  cat,  which  the  latter  is  not  permitted  to  reach,  or 
to  holding  a  cup  of  water  before  a  thirsty  man  without 
permitting  him  to  partake,  or  placing  a  starving  man  in  the 
neighborhood  of  a  jfine  dinner,  which  he  may  see  and  smell, 
but  is  not  permitted  to  touch.  In  a  way  this  condition  is 
even  worse  than  masturbation,  for  in  the  latter  the  process 
at  least  comes  to  orgasm,  ejaculation,  and  satisfaction, 
whereas  here  these  important  elements  are  merely  hinted 
at  but  not  experienced.  Moreover,  the  hyperemia  of  the 
pelvic  organs,  which  is  normally  relieved  with  the  orgasm 
and  its  accompanying  ejaculation,  does  not  disappear  if  the 
orgasm  fails  to  occur;  and,  if  the  condition  has  lasted  for 
a  long  time,  chronic  congestion,  with  all  its  accompanying 
sequelae,  results. 

In  masturbation  the  sensitiveness  of  the  external  geni- 
tals has  been  so  increased  at  the  expense  of  that  of  the 
vaginal  mucous  membrane,  and  the  sexual  centers  have  been 
so  dulled  and  almost  exhausted  by  the  frequent  demands 
made  on  them  by  the  oft-repeated  acts  of  masturbation, 


200  Disorders  of  the  Sexual  Function. 

that  the  ordinary  stimulation  of  the  act  of  coitus  is  not 
enough  to  arouse  them  sufficiently  to  bring  on  the  orgasm, 
and  the  latter  must  be  brought  on  by  titillation  of  the  clit- 
oris, or  other  masturbatory  act  of  the  hypersensitive  external 
genitals.  Another  pathological  condition  met  with  is  due 
to  a  disproportion  between  the  male  and  female  genitals. 
An  undeveloped  penis  may  not  come  into  that  intimate  con- 
tact with  the  vagina  which  is  necessary  to  sufficiently  excite 
the  sexual  centers.  Similarly  a  relaxed  condition  of  the 
vagina,  or  a  too  roomy  vagina,  as  the  result  of  lacerations 
after  childbirth,  will  have  the  same  result.  Pathological 
conditions  of  the  clitoris,  which  prevent  its  coming  into 
contact  with  the  male  organ  during  coitus,  are  a  very  fre- 
quent cause  of  lack  of  orgasm.  Among  such  conditions 
also  may  be  mentioned  absent  or  rudimentary  clitoris,  a 
clitoris  bound  down  by  adhesions,  or  an  abnormally  placed 
clitoris.  These  pathological  states  of  the  clitoris  explain 
why  in  some  cases  the  woman  experiences  orgasm  only 
when  coitus  is  performed  in  unusual  positions,  such  as 
lateral  or  even  reverse  positions  of  the  parties.  Perineal 
fissures  and  rectovaginal  and  vesicovaginal  fistulee  may  like- 
wise prevent  the  occurrence  of  the  orgasm.  Any  of  the 
pathological  conditions  which  cause  dyspareunia  may  at 
times  be  etiological  factors  in  hindering  the  completion  of 
coitus  and,  by  so  doing,  prevent  the  orgasm.  Certain  classes 
of  degenerates,  mainly  inverts,  often  have  marked  orgasm 
when  cohabiting  with  other  females,  and  also  with  lower 
animals,  but  never  with  men.  Many  of  the  etiological 
factors  in  frigidity  and  vaginismus  also  become  causes  of 
the  lack  of  orgasm. 


Absence  of  Orgasm  in  Female.  201 

Symptoms. — Many  of  the  symptoms  have  already  been 
hinted  at  in  discussing  the  pathology.  The  nervous  strain 
of  such  a  woman,  with  her  unappeased  though  stimulated 
sexual  appetite,  finally  leads  to  a  condition  of  nervous  irri- 
tability, sexual  neurasthenia,  and  hysteria.  The  condition, 
as  already  stated,  is  in  many  ways  worse  than  masturbation, 
and,  except  for  its  curability  in  some  cases,  is  worse  than 
frigidity.  The  totally  frigid  woman  knows  nothing  of 
sexual  passion,  and  therefore  misses  nothing  and  there  is 
therefore  no  strain  upon  her  nervous  system,  while  in  the 
condition  under  discussion  the  state  of  affairs  is  just  the 
reverse. 

As  a  result  of  the  chronic  congestion,  which  finally 
results,  in  the  pelvic  viscera,  we  have  a  train  of  symptoms, 
well  known  to  every  gynecologist,  which  appear  whenever 
there  is  chronic  congestion  of  these  parts  from  whatever 
cause.  It  is  not  necessary  to  enumerate  all  the  symptoms 
arising  from  this  chronic  congestion,  but  a  few  of  the  more 
common  ones  will  be  mentioned.  Among  these  are  back- 
ache, increased  frecjuency  of  urination  due  to  vesical  con- 
gestion, leucorrhea,  chronic  endometritis,  hemorrhoids,  etc. 

Most  German  authorities  lay  great  stress  upon  the  caus- 
ative relationship  of  lack  of  orgasm  to  sterility.  I  have 
discussed  this  question  elsewhere,^^  but  a  few  remarks  upon 
this  very  important  subject  may  not  be  amiss  here. 

Kisch^^  says  the  following: — 

'Tn  our  consideration  of  the  various  influences  by  which 
the  contact  of  ovum  a,nd  spermatozoon  may  be  prevented, 
the  degree  of  sexual  excitement  experienced  by  the  woman 
during  the  sexual  act  must  not  be  overlooked,  for  this  plays 


202  Disorders  of  the  Sexual  Function. 

a  part  not  to  be  underestimated,  even  though  it  is  a  matter 
on  which  it  is  difficult  to  obtain  accurate  information. 

"It  is  extremely  probable  that  an  active  participation  on 
the  part  of  the  woman  in  coitus  has  an  important  influence 
upon  the  attainment  of  fertilization,  i.  e.,  that  sexual  excite- 
ment in  the  woman  is  a  link  in  the  chain  of  conditions 
leading  to  conception.  This  excitement  has  a  reflex  in- 
fluence, but  the  influence  may  be  exercised  in  either  (or 
both)  of  two  ways :  first,  it  may  cause  certain  reflex  changes 
in  the  cervical  secretion,  whereby  the  passage  of  the  sper- 
matozoa is  facilitated;  or,  secondly,  it  may  give  rise  to 
reflex  changes  in  the  vaginal  portion  of  the  cervix,  to  a 
rounding  of  the  os  uteri  externum,  and  a  hardening  of  the 
consistency  of  the  cervix  (changes  of  an  erectile  nature), 
coupled  with  a  slight  descent  of  the  uterus, — changes  which 
likewise  favor  the  entrance  of  the  semen  into  the  uterine 
cavity.  Theopold  goes  so  far  as  to  say  that  it  is  only 
women  who  experience  erotic  excitement  who  are  capable 
of  being  impregnated. 

"My  own  opinion  is  that  considerable  importance  is  to 
be  attached  to  voluptuous  excitement  of  the  woman  during 
coitus,  for  the  former  of  the  two  reasons  mentioned  above, 
namely,  because  such  excitement  leads  to  the  occurrence  of 
reflex  secretion  of  the  cervical  glands,  the  secretion  thus 
produced  maintaining  or  enhancing  the  activity  of  the 
spermatozoa ;  and  contrariwise,  in  the  absence  of  voluptuous 
excitement  on  the  woman's  part  there  is  a  failure  of  the 
reflex  secretion,  and  the  passage  of  the  spermatozoa  into 
the  uterine  cavity  is  consequently  less  easily  effected." 

Rohleder^^^  explains  the  influence  of  lack  of  orgasm  as 


Absence  of  Orgasm  in  Female.  203 

a  causative  factor  in  sterility,  by  saying  that  at  the  height 
of  the  orgasm,  and  with  the  pouring  out  of  the  secretions 
of  the  Barthohnian  glands,  there  also  occurs  an  extrusion 
of  the  plug  of  mucus  from  the  cervical  os  (the  Kristeller). 
At  the  same  time  the  cervix  descends  to  meet  the  penis, 
and  the  peristaltic  wave  of  the  vaginal  musculature  com- 
mences at  the  entrance  of  the  vagina  and  extends  upward, 
thus  preventing  the  semen  from  flowing  out  of  the  vagina. 
This  results  in  forming  an  aspiratory  or  suction  action, 
by  which  the  spermatozoa  are  sucked  into  the  now  open  os. 
The  OS  uteri  also  opens  widely  and  assists  in  sucking  in 
the  spermatozoa.  If  orgasm  does  not  occur,  this  aspiratory 
action  is  either  absent  or  incomplete,  and  the  plug  of 
mucus  is  not  expelled  from  the  cervix,  all  of  which  has 
a  tendency  to  hinder  the  ascent  of  the  spermatozoa.  Most 
German  authorities  concur  in  this  explanation  by  Rolileder. 
I  have  shown  elsewhere^'  that  there  is  a  very  pro- 
nounced relationship  between  lack  of  sexual  passion  (fri- 
gidity) and  sterility.  Experiments  and  observations  upon 
animals,  mostly  by  breeders,  seem  to  support  Rohleder's 
views  as  given  above.  NeA'ertheless,  while  I  do  not  desire 
to  go  on  record  as  opposing  this  explanation  of  the  causal 
effect  of  lack  of  orgasm  to  sterility,  I  believe  the  causal 
relationship  has  been  greatly  exaggerated.  The  fact,  for 
instance,  that  pregnancy  may  follow  rape,  and  that  preg- 
nancy has  followed  the  mere  deposit  of  spermatozoa  upon 
the  external  genitals,  with  an  intact  hymen,  shows  that 
orgasm  is  not  absolutely  essential  to  impregnation.  But 
these  are  not  the  chief  reason  for  my  dissent.  ^ly  obser- 
vations with  cases  of  withdrawal  have  convinced  me  that 


204:  Disorders  of  the  Sexual  Function. 

the  act  of  withdrawal  is  not  by  any  means  a  good  pre- 
ventive measure  for  conception.  The  spermatozoa  have  a 
very  hvely  motion  of  their  own,  and  once  they  have  reached 
the  cervical  os,  in  the  presence  of  normal  female  genitalia, 
they  will  somehow  find  their  way  into  the  uterus  and 
Fallopian  tubes.  While  there  is  no  doubt  that  the.  aspira- 
tory  suction  greatly  favors  their  ascent,  I  do  not  believe 
it  to  be  as  essential  as  the  German  authorities  would  have 
us  believe.  Inasmuch,  also,  as  spermatozoa  may  remain 
alive  in  the  uterus  for  several  days,  it  can  be  readily 
understood  that  they  have  plenty  of  time  to  climb  up  into 
the  Fallopian  tube  even  without  any  suction  action  whatever. 

I  have  pointed  out  heretofore^^  that  a  very  frequent 
combination  met  with  is  the  infantile  or  undeveloped 
uterus,  scant  or  delayed  menstruation,  together  with  lack 
of  sexual  passion  and  sterility.  These  observations  lead  to 
the  conclusion  that  the  sterility  is  not  the  result  of  the 
lack  of  sexual  passion  or  the  lack  of  orgasm,  but  rather 
that  both  conditions  are  but  expressions  of  a  general  lack 
of  development  of  the  entire  sexual  apparatus,  anatomical 
as  well  as  physiological. 

There  is  another  class  of  unfortunate  women  who  have 
intense  sexual  desire,  but  in  whom  it  may  take  hours  of 
continuous  friction  to  bring  on  the  orgasm,  which  may 
even  never  come  on  at  all.  In  these  women  there  exists 
a  condition  bordering  on  nymphomania,  from  which,  how- 
ever, it  must  be  carefully  distinguished.  Those  afflicted 
in  this  way  constantly  demand  sexual  intercourse  with 
their  husbands,  and  will  exhaust  the  most  powerful  man. 
Being  excited,  they  will  demand  their  husbands  to  keep  up 


^Absence  of  Orgasm  in  Female.  205 

coitus  indefinitely  in  the  hope  of  obtaining  satisfaction  of 
orgasm.  They  are  able  to  perform  coitus  innumerable 
times  a  night,  and  yet  remain  unsatisfied.  The  pathologi- 
cal seat  in  this  class  of  cases  is  probably  to  be  sought  in 
one  of  the  sexual  centers,  which  seems  incapable  of 
responding  to  a  stimulus. 

Diagnosis. — The  diagnosis  is  made  from  the  history  of 
the  case.  The  essential  point  in  the  history  is  the  lack  of 
ejaculation.  Whenever  a  woman  states  that  she  remains 
dry  after  coitus,  it  generally  means  a  lack  of  orgasm.  The 
converse  however,  is  not  true,  for  a  woman  without 
orgasm  or  ejaculation  may  nevertheless  find  herself  wet, 
on  account  of  the  ejaculation  from  her  husband,  or  the 
flowing  out  of  his  semen  after  coitus.  We  must  take  the 
entire  history  into  consideration,  and  it  must  be  remem- 
bered that  some  women  deny  the  existence  of  orgasm  when 
it  really  does  occur  on  account  of  a  false  notion  of  modesty. 
Some  seem  to  be  ashamed  to  admit  it,  while  others  deny 
it  to  gain  sympathy  by  representing  themselves  to  be  mar- 
tyrs to  matrimony.  Wherever  possible,  therefore,  it  is 
desirable  to  obtain  the  husband's  version  of  her  condition 
at  coitus,  and  compare  the  two  histories.  The  fact  should 
also  be  borne  in  mind  that  while  the  voluptuous  feeling  of 
gratification  may  be  entirely  unknown  to  the  victim  from 
her  own  personal  experience,  she  may  still  know  of  it  from 
conversation  with  female  friends. 

As  above  stated,  the  condition  in  which  there  is  intense 
desire,  but  with  inability  to  arouse  the  orgasm,  must  be 
carefully  diagnosed  from  nymphomania.  In  the  latter  we 
will  obtain  a  history  of  distinct  orgasm  on  close  question- 


206  Disorders  of  the  Sexual  Function. 

ing.  The  only  similarity  between  the  two  is  the  intense 
desire  for  sexual  intercourse,  which  in  the  disease  under 
discussion,  is  due  to  the  unsatisfied  condition  in  which  the 
woman  is  left  after  coitus.  There  ought  be  no  difficulty 
in  distinguishing  lack  of  orgasm  from  vaginismus.  In 
vaginismus  there  is  no  orgasm  because  there  can  be  no 
proper  coitus,  while  in  the  former  condition  coitus  is  per- 
fectly possible. 

Prognosis. — This  depends  upon  the  possibility  of  remov- 
ing the  underlying  cause.  The  majority  of  etiological 
causes  are  remediable.  Those  cases  where  the  pathological 
seat  is  in  the  sexual  centers  and  their  inability  to  respond 
to  stimulation  are  perhaps  the  worst  of  all. 

Treatment. — The  treatment  varies  with  the  etiological 
causes.  It  may  have  to  begin  with  the  treatment  of  the 
male,  if  the  condition  is  due  to  impotence  or  premature 
ejaculation  on  his  part.  He  should  also  be  warned  against 
the  evil  consequences  of  withdrawal  not  only  to  himself 
but  also  to  his  partner.  He  may  have  to  be  instructed  in 
the  proper  method  of  performing  coitus,  not  only  for  his 
own  satisfaction,  but  also  for  that  of  his  wife.  These 
instructions  have  been  outlined  heretofore  on  pages  178  and 
179,  and  will  therefore  not  be  repeated  here. 

Any  pathological  condition  of  the  female  which  may 
have  an  etiological  bearing  should  be  remedied.  These 
include  such  conditions  as  perineal  fissures,  lacerations, 
adherent  clitoris,  as  well  as  masturbation,  dyspareunia, 
vaginismus,  etc.  (see  Etiology  and  Pathology).  For  ab- 
normal situations  of  the  clitoris,  or  abnormal  shortness  of 
that  organ,  it  is  perfectly  proper   for  the  parties  to  be 


Absence  of  Orgasm  in  Female.  20 Y 

instructed  to  experiment  with  out-of-ordinary  postures  dur- 
ing coitus,  for  the  purpose  of  bringing  the  clitoris  into 
better  contact  with  the  penis  and  so  exciting  the  orgasm. 
Where  nothing  else  can  be  done,  Rohleder^*^^  considers  it 
perfectly  proper  for  the  husband  to  resort  to  titillation  of 
the  clitoris  during  coitus  for  this  purpose.  No  matter  what 
attitude  we  may  take  toward  this  procedure,  we  must  ap- 
preciate that  we  are  very  often  confronted  with  alternatives 
far  more  serious,  such  as  unhappiness  in  the  marriage 
relationship,  possibility  of  divorce,  and  even  the  temptation 
of  the  wife  to  try  her  luck  elsewhere.  These  are  no  idle 
theories,  but  actual  occurrences.  We  must  remember  that 
married  women  talk  a  great  deal  about  such  matters  among 
themselves,  and  the  woman  will  soon  be  made  to  under- 
stand from  her  female  friends  what  she  misses.  If  there- 
fore we  have  exhausted  all  our  therapeutic  measures  without 
avail,  and  find  no  other  gynecological  condition  to  remedy, 
it  is  far  better  to  give  the  husband  the  advice  mentioned 
than  have  the  parties  run  the  chances  just  referred  to. 


CHAPTER  XV. 

ENURESIS. 

Definition.  Classification.  Etiology  and  pathology.  Enuresis  and 
epilepsy.  Symptoms.  Psychic  element.  Diagnosis.  Prognosis.  Treat- 
ment. "Wonderful  cures."  General  treatment.  Folly  of  punishment. 
Regulation  treatment.  Treatment  of  obstinate  cases.  Author's  ex- 
periments. Treatment  by  re-education.  Different  methods  of  treat- 
ment by  various  authors. 

Definition. — Enuresis  is  the  involuntary  evacuation  of 
urine  in  childhood  in  the  absence  of  any  gross  pathological 
condition  of  the  urinary  apparatus.  If  the  involuntary 
urination  takes  place  during  sleep,  it  is  called  enuresis  noc- 
turna;  if  during  waking  hours,  it  is  called  enuresis  diurna, 
and  if  both  by  day  and  night,  it  is  called  enuresis  continua. 
Involuntary  evacuation  of  the  bladder  is  normal  in  early 
infancy,  but  with  proper  training  a  child  may  be  enabled 
to  control  its  urine  by  day  as  early  as  the  tenth  month. 
Involuntary  micturition  at  night  continues  much  longer 
and,  while  some  pediatricians  do  not  consider  it  pathologi- 
cal even  if  it  continues  up  to  the  end  of  the  third  year, 
others  consider  it  pathological  after  the  completion  of  the 
second  year. 

Etiology  and  Pathology. — Inasmuch  as  the  normal  act 
of  urination  consists  in  a  reflex  expulsion  of  the  urine  by 
the  bladder,  controlled  by  inhibitory  impulses  from  the 
cerebrum,  any  condition  which  interferes  either  directly  or 
reflexly  with  this  mechanism  may  be  the  cause  of  enuresis. 

In  the  infant,  the  contraction  of  the  bladder  and  the 
relaxation  of  the  sphincters  are  purely  reflex  and  depend- 
(208) 


Enuresis.  209 

ent  upon  stimulation  of  the  centers  in  the  spinal  cord.  It 
takes  time  for  the  higher  centers  in  the  brain  to  gain  con- 
trol of  the  function  of  micturition  and  to  bring  it  under 
control  of  the  will. 

Enuresis  may  therefore  be  due  to  a  lack  of  development 
of  the  control  or  inhibition  of  the  higher  centers  in  the 
brain.  To  this  class  belong  the  enuresis  of  idiocy,  imbecil- 
ity, or  other  diseased  conditions  of  the  cerebrum. 

In  other  cases,  the  pathology  and  etiology  are  entirely 
different.  The  reflex  stimulation  from  the  bladder  may  be 
so  powerful  that  the  cerebral  inhibition  is  too  weak  to 
control  it,  as  in  the  case  in  hyperacidity  of  the  urine,  or 
any  other  local  condition  which  may  be  the  starting  point 
of  powerful  reflexes. 

In  order  that  the  lumbar  centers  be  stimulated  into 
action,  there  must  be  present  ordinarily  more  or  less 
distention  of  the  bladder.  In  some  cases  of  enuresis  there 
is  a  contracted  bladder  which  becomes  distended  with  very 
little  urine  in  it,  and  so,  especially  at  night,  the  reflex  is 
soon  started,  and  bed-wetting  results. 

In  other  cases  there  may  be  a  hyperirritability  of  the 
lumbar  centers  themselves.  In  these,  the  accumulation  of 
only  a  slight  amount  of  urine  in  the  bladder  is  enough  to 
start  such  a  powerful  reflex  as  to  overcome  the  inhibition 
of  the  higher  centers,  and  the  enuresis  here  is  associated 
with  increased  frequency  of  urination. 

In  other  cases  still,  the  control  of  the  higher  centers  is 
unduly  weak  while  the  lumbar  centers  are  normal.  This  is 
the  condition  of  affairs  in  ordinary  cases  of  nocturnal 
enuresis.     As  long  as  the  child  is  awake  the  controlling 

14 


210  Disorders  of  the  Sexual  Function. 

influence  of  the  higher  centers  is  sufficient  to  keep  things 
normal,  but  in  sleep,  with  this  control  less  powerful,  enu- 
resis ensues.  Even  by  day,  in  some  of  these  cases,  if  the 
child  is  deeply  absorbed  in  some  occupation,  the  control  of 
the  higher  centers  may  at  times  be  too  weak  to  prevent 
enuresis. 

•  In  many  instances,  however,  the  pathology  is  not  at  all 
clear.  Some  cases  appear  to  be  due  to  a  lack  of  proportion 
in  the  power  of  the  expulsion  muscles  of  the  bladder  and 
the  bladder-sphincters,  there  being  either  normal  sphincters 
and  exceedingly  powerful  expulsive  muscles,  or  normal 
expulsive  muscles  and  weak  sphincters.  In  still  another 
class  there  seems  to  be  a  lack  of  harmony  between  the 
nerves  which  control  the  expulsion  of  the  urine  and  those 
which  control  the  action  of  the  sphincters.  This  condition 
has  been  compared  to  the  act  of  stuttering  or  other  speech 
defects.  In  most  cases,  however,  we  cannot  discover  even 
a  hint  at  the  underlying  pathological  conditions,  and  this 
is  true  of  between  90  and  95  per  cent,  of  them.  Many 
theories  have  been  advanced  to  explain  these  idiopathic 
cases.  Both  Herrman"*®  and  Wachenheim^^^  believe  that 
they  belong  to  the  same  catagory  as  the  tics,  or  habit- 
spasms.  Some  instances  seem  to  be  hereditary,  for  we  find 
whole  families  in  which  the  majority  of  members  have 
always  suffered  from  enuresis  in  childhood.  In  other  in- 
stances, w^e  discover  a  condition  of  instability  in  the  nervous 
make-up  of  the  individual,  and  attention  has  already  been 
called  to  the  fact  that  many  individuals  who  suffer  from 
impotence  after  reaching  adult  life  have,  as  children,  suffered 
from  enuresis. 


Enuresis.  211 

It  was  assumed  formerly,  on  purely  theoretical  grounds, 
that  so-called  scrofula  or  malnutrition  was  an  etiological 
factor,  but  careful  observation  has  shown  the  reverse  to 
be  the  case,  for  well-nourished  children,  as  a  general  rule, 
suffer  more  from  this  condition  than  their  weaker  brethren. 
Both  hypothyroidism  and  hyperthyroidism  have  at  times 
been  the  cause  of  enuresis.  In  some  cases  the  administra- 
tion of  thyroid  has  proven  curative,  while  it  has  also 
happened  that,  in  children  normal  in  this  regard,  the  ad- 
ministration of  thyroid  for  some  other  ailment  has  brought 
on  enuresis. 

Among  additional  reflex  causes  may  be  mentioned  long, 
tight,  or  adherent  prepuce  and  balanitis  or  narrow  meatus 
in  the  male,  vaginitis  in  the  female,  as  well  as  rectal  worms, 
rectal  polyp,  or  anal  fissure,  kidney  disease,  bladder  disease, 
diabetes,  or  organic  nervous  disease. 

Burnet^ ^  claims  that  enuresis  coming  at  rare  intervals 
may  be  a  manifestation  of  epilepsy,  and  is  cured  by 
bromides. 

Many  years  ago  adenoids  were  considered  an  etiological 
factor,  but  experience  has  not  proven  the  causal  relation- 
ship. In  some  cases  the  removal  of  adenoids,  like  any 
other  psychic  shock,  has  caused  the  cessation  of  the  habit, 
but  it  has  also  happened  that  the  *-emoval  of  adenoids  has 
brought  on  enuresis  where  the  condition  had  not  existed 
before. 

Boys  and  girls  seem  to  suffer  in  equal  proportion.  In 
girls  the  condition  is  more  often  kept  secret  even  by 
parents,  which  accounts  for  the  opinion  that  boys  are 
afflicted  more  often  than  girls. 


212  Disorders  of  the  Sexual  Function. 

Symptoms. — In  some  cases  the  bed-wetting  is  simply  a 
continuation  of  the  normal  condition  of  infancy.  The  child 
simply  continues  its  nocturnal  or  diurnal  enuresis  without 
any  interval  of  control.  In  other  instances,  however,  the 
child  had  gained  its  normal  control,  and  remained  normal 
perhaps  for  several  years  before  the  enuresis  developed. 
In  this  latter  group  I  have  been  impressed  with  the  fact 
that  often  the  starting  point  was  some  illness.  Thus,  in 
not  a  few  cases  parents  have  told  me  that  the  child  was 
entirely  normal  until  an  attack  of  measles  or  diphtheria, 
and  one  of  my  oldest  cases  was  a  young  man  of  17  who 
informed  me  that,  when  8  years  of  age,  both  he  and  his 
brother  (four  years  younger)  were  ill  with  scarlet  fever, 
and  that  both  of  them  had  suffered  from  nocturnal  enuresis 
ever  since. 

Except  In  the  very  severe  cases,  the  children  do  not 
wet  the  bed  every  night,  but  generally  skip  one  or  two 
nights  a  week.  Those  suffering  from  enuresis  diurna  suffer 
almost  always  from  enuresis  nocturna  as  well,  while  chil- 
dren suffering  from  enuresis  nocturna  are  generally  able  to 
control  their  water  during  the  day.  Many  of  the  latter, 
however,  if  not  allowed  to  leave  the  room  promptly  at 
school,  pass  the  water  in  their  clothes.  This  is  not  true 
enuresis,  however,  as  it  is  not  done  unconsciously,  but  is 
simply  due  to  feeble  control. 

There  is  the  greatest  irregularity  in  cases  of  nocturnal 
enuresis,  whether  treated  or  not.  In  some,  without  any 
reason  whatsoever,  a  child  will  not  wet  the  bed  for  one 
or  two  weeks  at  a  time,  and  then  continue  the  wetting  as 
before.     If  a  new  remedy  is  tried  at  just  this  period,  the 


Enuresis.  213 

physician  is  apt  to  be  very  enthusiastic  and  credit  the  result 
to  the  treatment.  The  psychic  element  is  generally  well 
marked  in  these  cases,  it  being  a  well-known  fact,  that  al- 
most any  new  procedure  will  stop  the  condition  temporarily. 

Diagnosis. — The  main  point  in  diagnosis  is  to  exclude 
any  pathological  condition  as  a  possible  cause.  The  urine 
should  always  be  examined  as  a  matter  of  routine,  so  as 
to  exclude  the  possible  presence  of  diabetes,  and  we  will 
also  learn  from  this  examination  whether  hyperacidity 
exists.  In  special  cases  we  may  have  to  examine  the  urine 
for  tubercle  bacilli,  as  tuberculosis  of  the  kidneys  and  blad- 
der have  been  known  to  be  among  the  causes  of  enuresis. 
Such  conditions  as  vesical  calculus,  cystitis,  and  urethritis 
must  likewise  be  excluded  as  possible  causes,  and  we  must 
diagnose,  if  possible,  whether  the  underlying  cause  has  its 
seat  in  the  cerebrum,  the  lumbar  centers,  or  in  the  genito- 
urinary tract.  After  all,  however,  over  90  9c  of  the  cases 
are  idiopathic,  i.  e.,  we  can  find  no  pathological  condition 
either  in  the  local  genitourinary  organs  or  in  the  assimila- 
tive apparatus. 

Prognosis. — No  matter  how  obstinate  these  cases  may 
be,  most  of  them  recover  at  puberty.  The  younger  the 
child,  the  better  the  prognosis,  for  where  the  condition  con- 
tinues beyond  puberty  it  is  more  likely  to  be  very  obstinate. 
Even  here,  however,  most  cases  are  cured  with  proper 
treatment  and  great  patience  and  perseverance  on  the  part 
of  physician  and  parents.  Enuresis  in  idiots,  imbeciles,  or 
sufferers  from  other  grave  cerebral  conditions  is  apt  to 
remain  incurable.  The  prognosis  as  a  general  thing  de- 
pends  more   upon   the   patience   and  perseverence   of   the 


214  Disorders  of  the  Sexual  Function. 

physician  than  upon  any  other  factor,  since  90%  of 
the  cases  are  idiopathic,  without  discoverable  cause  to  work 
upon.  The  physician  must  not  get  discouraged  because'  the 
child  does  not  respond  to  treatment  for  a  long  time;  nor 
must  he  stop  treating  the  child  because  it  apparently  re- 
sponds very  favorably  to  his  first  medication.  Such  response 
is  very  apt  to  be  temporary  only,  and  he  must  therefore  have 
patience  with  both  classes  and  keep  them  under  treatment 
and  observation  for  a  long  time.  The  parents  should  also 
be  told  that  long  treatment  and  observation  are  necessary 
to  effect  a  permanent  cure. 

Treatment.  — Several  years  ago,  through  the  courtesy  of 
Dr.  Charles  Herrman,  at  that  time  Chief  of  the  Pediatric 
Department  of  Vanderbilt  Clinic,  New  York  City,  I  made 
a  special  study  of  the  enuresis  cases  coming  to  that  insti- 
tution, and  made  myself  acquainted  with  all  the  available 
literature  on  the  subject  as  well. 

I  was  struck  with  the  fact,  however,  that  while  many 
wonderful  and  quick  cures  are  mentioned,  many  of  these 
cures  failed  entirely  or  relieved  the  patient  only  temporarily 
when  I  gave  them  a  trial. 

As  I  became  more  experienced  in  the  management  of 
these  cases,  the  explanation  of  these  reported  "cures" 
became  clear.  There  is  a  very  marked  psychic  element 
about  enuresis,  and  any  new  therapeutic  agent,  be  it  elec- 
tricity, silver-nitrate  instillation,  passing  a  sound,  or  a  new 
prescription  will  temporarily  stop  it.  Most  of  these  "won- 
derful" cures  mentioned  are  also  quick  cures,  having  been 
reported  by  the  physician,  after  he  had  tried  them  for  a 
few  weeks  only,  and  before  the  psychic  element  had  worn 


Enuresis.  215 

off.  For  this  reason,  a  cure  with  any  new  remedy  ought 
not  to  be  reported  until  at  least  six  months  have  passed, 
to  ascertain  whether  the  result  is  permanent. 

General  Treatment. — The  general  treatment  is  very  im- 
portant and  should  be  carried  out,  no  matter  what  regu- 
lation treatment  is  applied.  In  many  cases,  it  is  useless 
to  attempt  to  treat  enuresis  without  due  regard  to  diet, 
mode  of  living,  and  other  factors  to  be  described  presently. 

In  the  first  place,  we  must  look  for  any  local  or  gen- 
eral irritation,  and  treat  this  condition.  This  includes  such 
sources  of  irritation  as  long,  tight,  or  adherent  prepuce, 
hyperacid  urine,  rectal  worms,  vesical  calculus,  vaginitis, 
urethritis,  or  any  of  the  other  conditions  mentioned  under 
Etiology  and  Diagnosis.  These,  however,  amount  to  about 
10%  only  of  all  cases  of  enuresis. 

The  child  should  sleep  upon  its  side,  for  many  children 
wet  the  bed  only  when  lying  flat  upon  their  backs.  For 
this  purpose,  wherever  necessary,  a  towel  may  be  tied 
around  the  child's  body,  with  the  knot  so  placed  as  to 
press  upon  its  back  when  lying  upon  the  back.  The  dis- 
comxfort  of  this  knot  will  compel  the  child  to  lie  upon  its 
side.  I  do  not  think  it  necessary,  however,  to  blister  the 
sacrum  in  order  to  keep  the  child  off  its  back. 

It  is  also  advisable  to  have  the  pelvis  of  the  child 
elevated  during  sleep.  This  has  the  effect  of  causing  the 
urine,  which  accumulates  in  the  bladder  during  the  night, 
to  gravitate  toward  the  fundus,  that  is,  away  from  the 
trigonal  region.  It  is  the  irritation  of  the  urine  against  the 
trigonal  region  which  often  starts  the  reflex  of  urination. 
The   elevation   of   the   pelvis   can  easily  be   accomplished 


216  Disorders  of  the  Sexual  Function. 

either  by  raising  the  foot  of  the  bed  or  by  putting  a  pillow 
under  the  child's  pelvis. 

It  is  advisable  likewise  to  have  someone  note  the  time 
the  child  wets  the  bed  during  the  night,  and  then  to  wake 
up  the  child  just  previous  to  that  time  on  succeeding  nights, 
and  have  it  empty  its  bladder.  This  is  an  excellent  method 
of  procedure,  but  entails  a  large  amoimt  of  inconvenience 
on  the  part  of  the  parents,  unless  they  happen  to  be  wealthy 
enough  to  afford  a  special  night  nurse.  To  avoid  this 
staying  up  and  watching  on  the  part  of  the  parents,  an 
ingenious  device  has  been  suggested,  which  consists  of  hav- 
ing one  pole  of  a  battery  in  contact  with  the  diaper  cover- 
ing the  child's  genitals,  and  so  arranged  that  as  soon  as 
the  diaper  is  wet,  a  circuit  is  completed  which  rings  an 
electric  bell  waking  up  the  child  or  parent.  I  have  had  no 
personal  experience  with  this  method,  and  cannot  therefore 
state  whether  it  is  practical. 

It  is  always  advisable  to  have  the  child  empty  its 
bladder  just  before  retiring,  and,  if  not  inconvenient,  to 
do  so  again  before  the  parents  retire,  just  before  midnight. 

It  is  absolutely  useless  and  often  harmful  to  punish  a 
child  for  bed-wetting.  It  is  far  better  to  reward  it  for 
the  nights  when  it  does  not  do  so.  In  enuresis  diurna  it 
is  well  to  appeal  to  the  child's  pride,  for  in  some  of  these 
cases  the  enuresis  is  kept  up  as  a  matter  of  habit,  some- 
times from  sheer  laziness  on  the  child's  part.  In  cases 
of  contracted  bladder,  it  is  well  to  develop  its  capacity  by 
having  the  child  retain  its  urine  at  longer  and  longer  inter- 
vals during  the  day,  or  by  gradual  distention  of  the  bladder 
with  fluid,  by  the  physician,  through  a  catheter. 


Enuresis.  217 

When  the  urine  is  normal,  it  is  best  to  reduce  the 
quantity  of  fluid  taken  by  the  child  during  twenty-four 
hours  by  at  least  25^.  If,  however,  the  urine  is  hyper- 
acid, this  reduction  would  only  make  matters  worse,  by 
increasing  the  relative  hyperacidity. 

A  diet  rich  in  sugar  or  starch  is  to  be  strictly  avoided 
and  often  an  antidiabetic  diet  is  of  distinct  value.  Red 
meat  should  be  given  only  once  during  the  twenty-four 
hours.  The  last  meal  should  be  taken  not  later  than  6  p.m., 
and  should  be  "dry"  and  not  very  heavy.  At  this  meal  we 
may  allow  cereals,  butter,  sugar,  ice-cream,  milk-toast,  fruit 
and  bread. 

After  4  P.M.  no  fluid  is  to  be  given  to  the  child  at  all. 
This  rule  must  be  rigidly  enforced,  except  for  the  first 
week,  when  a  little  fluid  may  be  permitted,  the  quantity 
of  which  is  to  be  gradually  reduced  until  the  child  is  used 
to  the  regimen. 

Regulation  Treatment. — For  the  regular  treatment  of 
enuresis,  nothing  has  thus  far  superseded  belladonna  pushed 
to  its  physiological  limit  and  persisted  in  for  a  long  time. 
I  can  do  no  better  than  recommend  the  method  of  admin- 
istration advocated  by  Kerley,  which  I  have  followed  with 
good  results  in  most  cases.  One  must  follow  his  scheme 
as  closely  as  possible,  however,  and  parents  must  be  warned 
in  advance  concerning  the  physiological  effects  of  this 
drug,  so  that  they  may  stop  it  at  the  right  time. 

Kerley^^  recomends  a  i :  500  solution  of  atropine,  each 
drop  of  this  solution  representing  gr.  ^/goo  of  atropine.  Of 
this  solution  he  prescribes  i  drop  twice  daily,  at  4  and  7 
P.M.  increasing  the  dose  until  the  physiological  effect  (di- 


218  Disorders  of  the  Sexual  Function. 

lated  pupils  or  redness  of  the  skin)  is  produced.  The 
administration  must,  however,  not  exceed  a  maximum  of 
I  drop  for  each  year  o£  the  child's  age.  Thus,  a  child  3 
years  old  should  never  receive  more  than  3  drops  of  the 
solution  twice  a  day;  one  6  years  old  should  never  receive 
more  than  6  drops  twice  a  day.  As  a  general  thing,  the 
physiological  effect  will  be  produced  before  this  maximum 
is  reached.  Kerley  gives  the  following  scheme  for  a  child 
5  years  of  age: — 


4  P.M. 

7  P.M. 

1st   day 

0  drop 

1  drop 

2d      '• 

1      " 

2  drops 

3d      " 

2  drops 

2     ■• 

4th    " 

2     " 

3      " 

Sth    " 

3     " 

3     " 

6th    '■' 

3     " 

4     " 

7th    " 

4     " 

4     " 

Sth    " 

5     " 

S     " 

We  must  not  be  discouraged  if  no  improvement  appears 
for  two  or  three  weeks.  The  diurnal  cases  respond  m.ore 
quickly  than  the  nocturnal,  that  is  to  say,  if  the  child  suf- 
fers both  by  day  and  night,  it  will  first  cease  its  involun- 
tary evacuation  by  day,  and  it  will  not  be  until  some  time 
later  that  any  improvement  will  be  noted  by  night.  The 
first  improvement  noted  at  night  will  be  a  diminution  in 
the  number  of  wet  nights.  It  may  take  a  few  weeks  before 
the  child  has  an  entirely  dry  week,  but  when  this  occurs 
the  treatment  must  not  be  stopped,  else  the  child  is  sure 
to  have  a  relapse.  If  the  child  has  had  two  dry  weeks, 
we  may  reduce  the  amount  of  drug  by  one-half  and  keep 
up  this  amount  for  six  weeks.  If  there  have  been  two  dry 
months,  however,  we  may  stop  the  drug  entirely,  keeping 


Enuresis.  219 

up  the  dry  suppers  for  three  months  longer.  In  diurnal 
enuresis  (without  nocturnal)  the  same  scheme  should  be 
followed  except  that  the  atropine  should  be  given  after 
breakfast  and  after  lunch  instead  of  at  4  and  7  p.m.,  while 
strychnine  should  be  given  at  the  same  time. 

Treatment  of  Obstinate  Cases. — Most  of  the  so-called 
obstinate  cases  are  cases  in  which  the  above  method  of 
treatment  had  not  been  persisted  in  long  enough,  the  physi- 
cian or  patient  having  become  discouraged.  Kerley  has 
shown  what  can  be  done  in  so-called  incurable  enuresis. 
He  put  some  of  these  patients  on  the  above  method  of 
treatment,  and  although  some  of  them  did  not  show  im- 
provement for  several  months,  still  he  persisted,  continuing 
to  treat  them  without  interruption  for  an  entire  year.  They 
were  entirely  cured,  and  although  he  kept  them  under 
observation  for  six  months  longer,  there  was  no  relapse. 

Several  years  ago,  I  had  under  treatment  a  bright  boy 
of  9  years  of  age  who  had  suffered  from  enuresis  for 
about  six  years.  He  was  kept  under  continuous  treatment 
of  one  kind  or  another  for  a  period  of  over  two  years, 
with  but  little  improvement.  I  carefully  followed  out  the 
above  scheme  with  no  result  whatever.  The  reason  that 
it  failed  was  possibly  due  to  the  fact  that  the  boy  seemed 
to  have  a  tolerance  for  the  drug.  I  then  increased  the  drug 
until  he  received  over  twice  the  maximum  dose  for  his 
age,  yet  there  was  absolutely  no  sign  of  a  physiological 
effect  either  in  the  pupils,  the  skin,  or  the  pulse.  I  tested 
his  bladder  capacity  and  found  it  even  above  normal,  for 
he  could  easily  hold  over  10  ounces  of  urine  during  the 
day.    I  tried  strychnine,  thyroid,  stypticin,  cantharides,  but 


220  Disorders  of  the  Sexual  Function. 

all  without  result.  The  only  thing  that  had  some  slight 
effect  was  deep  instillations  of  silver  nitrate  into  his  pos- 
terior urethra.  After  two  years  of  treatment  his  parents 
became  discouraged,  stopped  everything,  and  I  have  not 
heard  whether  anything  further  was  done. 

While  studying  these  cases  at  the  Vanderbilt  Clinic,  I 
experimented  to  ascerain  what  could  be  done  in  so-called 
obstinate  cases,  by  treatment  directed  to  the  urethra.  I 
gave  deep  instillations  of  weak  silver-nitrate  solution  into 
the  deep  and  anterior  urethra,  and  was  rather  surprised  to 
see  how  well  these  children  will  admit  of  such  instrumen- 
tation, if  the  procedure  is  done  with  due  gentleness.  In  a 
few  of  these  obstinate  cases,  I  have  had  some  permanent 
successes;  in  others,  however,  no  beneficial  result  was 
obtained.  On  the  other  hand,  I  have  never  seen  the  slight- 
est harm  follow  this  method.  Curiously  enough,  my  best 
results  were  obtained  in  females,  by  instilling  silver  nitrate 
into  the  urethra  with  a  sound  syringe. 

I  have  often  noticed  that  adults,  after  the  prostate  had 
been  massaged,  experienced  difficulty  in  starting  the  stream 
of  urine.  The  massage  seems  to  have  an  inhibitory  effect 
in  most  cases.  Acting  upon  this  experience,  I  thought  that 
massage  might  possibly  have  a  similar  effect  in  enuresis, 
and  accordingly  tried  this  procedure  upon  a  series  of  cases 
at  the  Vanderbilt  Clinic,  though  without  any  beneficial 
result  whatever.  In  one  instance,  I  had  a  rather  peculiar 
experience,  but,  as  this  was  an  isolated  case,  it  is  difficult 
to  say  whether  it  was  merely  a  coincidence  or  the  result 
of  the  treatment. 

The  case  was  that  of  a  little  boy  about  8  years  of  age, 


Enuresis.  221 

whose  enuresis  had  been  reduced  by  belladonna  treatment 
before  he  was  referred  to  me  to  one  bed-wetting  every  two 
weeks.  Further  belladonna  treatment,  likewise  before  he 
came  to  me,  did  not  relieve  this  semimonthly  bed-wetting. 
I  started  to  massage  his  prostate  once  a  week,  with  the 
result  that  almost  immediately  the  enuresis  increased  to  five 
wet  nights  a  week,  and  later  on  to  every  night.  After  that 
the  case  proved  very  obstinate,  even  though  the  massage 
was  stopped  after  but  three  treatments. 

It  would  take  me  far  beyond  the  limits  of  this  treatise 
to  state  all  the  methods  and  drugs  which  have  been  em- 
ployed for  the  relief  of  obstinate  cases  of  enuresis.  A  few 
of  the  more  important  ones,  however,  may  be  mentioned. 

On  the  theory  that  enuresis  is  a  habit  spasm,  it  has  been 
recommended  to  treat  the  condition  by  re-education.  Ac- 
cordingly, Herrman^^  treats  his  patients  as  follows: — 

"He  has  the  patient  urinate  at  regular  stated  times,  but 
on  each  occasion  he  is  directed  to  void  a  little, — say,  2 
drams ;  then  stop,  void  2  drams  more,  and  stop  again.  This 
is  continued  until  the  bladder  is  emptied.  This  procedure 
exercises  the  mechanism  which  controls  urination;  and  the 
patient  trains  and  educates  himself  in  the  voluntary  execu- 
tion of  the  act.  After  this  has  been  done  under  the  direc- 
tion of  the  physician  for  two  or  three  times,  the  patient 
can  continue  it  by  himself." 

Williams  reported  remarkable  results  from  the  use  of 
desiccated  thyroid.  He  administered  gr,  j4  of  dried 
thyroid  twice  daily  to  children  between  2  and  6  years  of 
age,  and  somewhat  larger  doses  to  older  children, 
Ruhrah^°^  also  tried  this  drug  in  cases  which  seemed  to  be 


222  Disorders  of  the  Sexual  Function. 


suffering  from  thyroid  insufficiency,  and  states  that  he  has 
had  considerable  success  in  a  series  of  cases.  The  results 
were  very  prompt,  coming  on  within  a  week  of  treatment, 
sometimes  even  after  the  first  or  second  dose.  In  fact, 
according  to  him,  no  response  can  be  expected  unless  the 
result  is  prompt.  In  this  connection  Williams  noticed  a 
marked  increase  in  weight  while  children  were  taking  the 
thyroid, — in  one  case,  a  gain  of  five  pounds  in  a  single 
week.  According  to  Ruhrah,  the  thyroid  need  not  be  con- 
tinued for  a  long  time. 

Lumbar  puncture  has  been  recommended  by  some 
authorities,  but  Allaria^  states  that  he  has  obtained  results 
just  as  good  with  pseudo-lumbar  puncture.  The  procedure 
in  both  is  the  same,  except  that  the  solution  is  injected  into 
the  subcutaneous  tissue  instead  o-f  into  the  spinal  cord. 
Allaria  states,  however,  that  marked  results  are  not  ob- 
tained by  either  method,  and  that  whenever  they  occur 
they  are  really  due  to  the  psychic  effect. 

Radcliffe*^^  has  obtained  good  results  from  taka-diastase 
in  cases  associated  with  glycosuria. 

Burnet^^  has  called  attention  to  the  fact  that  enuresis 
coming  on  at  long  intervals  may  be  merely  an  expression 
of  nocturnal  epilepsy  and  be  cured  by  bromides. 

Coutts^^  highly  recommends  the  tincture  of  lycopodium, 
in  doses  of  gtt.  20  to  a  dram  t.  i.  d.  He  says  it  is  almost 
a  specific,  but  I  have  had  considerable  difficulty  in  obtain- 
ing tincture  of  lycopodium,  many  druggists  claiming  that 
no  such  preparation  exists.  In  one  case  in  which  I  tried  it, 
however,  the  result  was  excellent. 

Electricity  has  been  recommended  by  various  author- 


Enuresis.  223 

ities.  I  have  tried  it  on  several  occasions  and  sometimes 
with  success,  but  believe  that  in  the  latter  the  influence 
was  purely  psychic. 


CHAPTER  XVI. 

THE  EVIL  CONSEQUENCES  OF  WITHDRAWAL. 

General  considerations.  Importance  to  general  practitioners.  Defi- 
nition. Etiology.  Pathology.  Physiology  of  normal  coitus.  Pathol- 
ogy of  withdrawal.  Importance  of  experience  in  posterior  endoscopy. 
Effect  of  withdrawal  on  female  organs.  Ignorance  of  the  male  about 
coitus.  Symptoms.  Local  symptoms.  Reflex  symptoms.  Illustrative 
cases.     Diagnosis.    Course  and  prognosis.     Treatment. 

Foreword. — The  practice  of  withdrawal  is  one  of  the 
oldest  and  most  wide-spread  of  sexual  sins.  Although 
many  years  ago  Bangs'''  and  others  have  called  attention  to 
the  evil  consequences  following  this  practice,  and  P^  have 
recently  reported  some  interesting  sequelae  in  the  same 
connection,  the  subject  is  of  such  great  importance,  and  is 
so  little  appreciated,  that  I  have  decided  to  devote  an  entire 
chapter  thereto. 

It  must  be  emphasized  at  the  outset,  that  the  evil  effects 
of  this  practice  are  not  of  interest  merely  to  the  genito- 
urinary specialist,  the  neurologist,  and  psychiatrist,  but 
they  are  even  of  more  immediate  interest  to  the  general 
practitioner.  There  is  hardly  an  organ  in  the  body  whose 
functions  may  not  be  deranged  through  reflexes  from  the 
genitals  arising  therefrom.  Besides  the  symptoms  of  gen- 
eral neurasthenia,  I  have  elsewhere^^  reported  a  case  of 
symptomatic  sciatica  which  resisted  all  treatment  for  a  long 
time  vmtil  it  was  referred  to  me.  I  was  able  to  bring 
about  a  cure  in  a  short  time  by  local  treatment  to  the 
patient's  prostate,  the  condition  being  due  to  withdrawal. 
The  patient  had  previously  made  no  mention  of  this  at  all 
(224) 


Withdrawal.  225 


in  giving  his  history,  not  thinking  it  had  any  relation  to 
his  "sciatica."  Another  case,  which  will  be  reported  here- 
in, presented  symptoms  which  suggested  cardiac  disease. 
These  symptoms,  lasting  for  years,  and  baffling  the  diagnos- 
tic abilities  of  several  excellent  internists,  were  due  to  no 
other  cause  than  to  reflexes  starting  from  an  insulted  sex- 
ual apparatus. 

It  is  for  just  this  reason  that  the  general  practitioner 
must  be  interested  in  this  condition  and  constantly  bear  it 
in  mind  as  a  frequent  etiological  factor.  The  patient  does 
not  know  or  suspect  that  this  practice  can  harm;  nor  does 
he  corne  to  the  physician  saying  that  he  practises  with- 
drawal and  has  such  and  such  symptoms.  Far  from  it. 
He  may  com.e  complaining  of  headache,  or  frequency  of 
urination,  or  fainting  spells,  or  attacks  of  vomiting,  or 
excessive  perspiration,  etc.,  and  it  is  only  after  tactful  and 
painstaking  cross-examination  (especially  in  women)  that 
the  etiological  factor  of  withdrawal  is  elicited. 

Definition.  — Coitus  interruptus,  or  "withdrawal"  (by 
some  called  Onanism),  is  the  voluntary  interruption  of 
coitus  by  withdrawing  the  penis  from  the  vagina  before 
ejaculation  takes  place.  We  must  include  herein  any 
attempt  on  the  part  of  the  patient  to  withdraw  the  penis 
before  completed  coitus,  Vv^hether  successful  or  not. 

Etiology. — The  object  of  the  procedure  is  to  prevent 

impregnation  by  having  the  ejaculation  take  place  outside 

of  the  female  genitals.     In  most  cases  there  is  a  deliberate 

understanding  between  husband  and  wife  to  do  this,  and 

in  other  cases  it  is  only  the  wife,  who  does  not  wish  to 

be  annoyed  with  the  inconveniences  attendant  upon  child- 
is 


226  Disorders  of  the  Sexual  Function. 

bearing,  who  compels  her  husband  to  resort  to  this  pactice. 
Economic  stress  is  the  reason  generally  given,  and  it  is 
indeed  rare  for  the  woman  to  avoid  pregnancy  on  account 
of  the  pains  of  labor.  There  are  many  other  reasons  given 
by  both  parties  why  they  desire  to  avoid  pregnancy,  but 
the  economic  reason  is  the  one  most  common. 

Pathology. — To  understand  the  pathology  of  withdrawal 
it  is  necessary  to  have  a  clear  idea  of  the  physiology  of 
normal  coitus,  for,  as  in  other  conditions,  the  pathology 
is  but  perverted  physiology. 

The  physiology  of  normal  coitus  in  the  male  has  al- 
ready been  given  on  pages  62-69,  and  the  pathology  of 
coitus  interruptus  in  the  male  has  also  been  given  on  pages 
70-73.  Only  a  brief  description  of  the  essential  points  of 
the  physiology  of  normal  coitus  as  well  as  the  pathology 
of  coitus  interruptus  will  therefore  be  given  here. 

At  the  commencement  of  normal  coitus,  the  seminal 
vesicles  are  more  or  less  completely  distended  and  impulses 
are  sent  from  them  to  the  erection  center.  The  latter  also 
receives  impulses  from  the  cerebrum  as  well  as  from  the 
glans  penis  during  the  friction  of  coitus.  (See  diagrams, 
page  6y.)  Normally  the  erection  center  does  not  send  out 
impulses  to  the  ejaculation  centers  until  it  is  completely 
filled  up  with  the  impulses  it  has  received  from  the  cere- 
brum, the  seminal  vesicles,  and  the  glans  penis.  In  this 
way  ejaculation  does  not  take  place  until  an  appreciable 
time  after  the  commencement  of  coitus.  The  result  is  that 
the  seminal  vesicles  are  almost  completely  emptied  and  the 
erection  center  is  left  in  a  condition  of  complete  quietude. 
The  desire  for  coitus  therefore  does  not  come  back  for  a 


Withdrawal.  227 


long  time,  until  the  seminal  vesicles  have  again  become 
completely  distended,  by  which  time  the  erection  center  as 
well  as  the  ejaculation  centers  have  completely  recovered 
from  tbeir  state  of  temporary  exhaustion.  This  time  varies 
normally  in  different  individuals.  As  a  further  result  of 
normal  coitus,  the  mucous  membrane  of  the  prostatic 
urethra,  which  just  before  and  during  coitus  has  been 
markedly  hyperemic,  has  lost  its  congestion.  The  mucous 
membrane  having  resumed  its  normal  condition,  does  not 
send  impulses  to  the  cerebrum  until  it  is  again  rendered 
hyperemic  at  the  next  coitus. 

Let  us  now  see  what  happens  to  all  these  parts  as  a 
result  of  the  repeated  practice  of  withdrawal.  If  the  act 
of  coitus  is  stopped  before  it  is  completed,  the  seminal 
vesicles  have  not  been  able  to  completely  empty  themselves, 
or  to  empty  themselves  as  completely  as  during  a  normal 
coitus,  and  are  thus  left  more  or  less  filled.  The  mucous 
membrane  of  the  prostatic  urethra  has  not  been  able  to 
completely  deplethorize  itself,  and  thus  remains  more  or 
less  congested  after  the  act.  As  a  result  of  all  this,  im- 
pulses are  sent  much  sooner  from  the  distended  vesicles 
and  the  prostatic  urethra  to  the  erection  center  and  the 
cerebrum,  so  that  the  desire  for  coitus  is  felt  sooner  than 
after  normal  coitus.  The  act  is  therefore  repeated  more 
frequently  than  it  would  have  been  in  that  particular 
individual  after  a  normal  coitus. 

The  seminal  vesicles,  being  never  completely  emptied 
during  withdrawal  coitus,  are  constantly  sending  impulses 
to  the  erection  center,  while  the  mucous  membrane  of  the 
prostatic  urethra,  being  in  a  condition  of  chronic  conges- 


228  Disorders  of  the  Sexual  Function. 

tioii  in  consequence  of  repeated  acts  of  withdrawal,  is 
likewise  sending  continuous  impulses  to  the  same  center 
whether  coitus  is  indulged  in  or  not.  The  result  of  these 
continued  impulses  sent  from  both  sources,  as  well  as  the 
repeated  demands  made  upon  the  center  itself  from  the 
oft-repeated  acts  of  coitus,  is,  that  the  erection  center  does 
not  completely  recover  itself,  and  finally  remains  in  a  state 
of  hyperexcitability.  It  thereupon  loses  its  inhibitory  func- 
tion, and  sends  out  impulses  to  the  ejaculation  centers  the 
very  moment  it  receives  them.  We  thus  get  the  clinical 
condition  of  rapid  ejaculation  or  even  premature  ejacula- 
tion at  the  very  commencement  of  coitus,  with  little  or  no 
erection.  It  must  be  remembered,  however,  that  all  this 
does  not  occur  as  a  result  of  a  single  act  of  withdrawal, 
but  only  after  repeated  insults  to  the  sexual  apparatus,  and 
it  is  often  only  after  years  of  this  practice  that  the  harmful 
effects  above  described  become  evident.  This  condition  of 
rapid  ejaculation  and  later  of  premature  ejaculation  is  the 
first  stage  of  impotence.  In  the  latter  condition  the  erec- 
tion center  has  become  so  hyperirritable  that  it  sends  out 
impulses  to  the  ejaculation  centers  at  the  very  first  prepa- 
rations for  coitus,  and  ejaculation  takes  place  before  the 
penis  has  become  sufficiently  erect  to  enter  the  vagina.  As 
a  final  result  of  a  more  or  less  prolonged  period  of  hyper- 
irritability  of  the  erection  center,  the  latter  finally  becomes 
completely  exhausted  and  refuses  to  send  out  any  impulses 
at  all.  The  condition  then  becomes  one  of  complete  impo- 
tence, in  which  neither  ejaculation  nor  erection  can  take 
place  at  all,  no  matter  how  strong  are  the  impulses  sent 
from  the  cerebrum,  the  seminal  vesicles,  or  the  penis. 


Withdrawal.  229 


If  the  posterior  urethra  be  examined  with  the  endoscope 
after  the  patient  has  practised  withdrawal  for  a  long  time, 
we  will  find  it  in  a  condition  of  marked  hyperemia.  As 
a  general  thing  the  verumontanum  will  be  found  to  be  not 
only  congested  but  swollen.  One  must  have  considerable 
experience,  however,  before  he  can  determine  what  consti- 
tutes congestion  in  the  posterior  urethra,  because  the  region 
of  the  verumontanum  is  normally  of  a  darker  red  than  the 
other  parts  of  the  urethra,  and  the  pressure  of  the  instru- 
ment also  causes  abnormality  in  the  color  of  the  urethral 
mucous  membrane.  With  experience  we  can  easily  demon- 
strate a  condition  of  chronic  congestion  which  must  be 
seen  to  be  appreciated.  Moreover,  it  takes  considerable 
experience  in  posterior  urethroscopy  before  the  enlarge- 
ment of  the  verumontanum  can  be  recognized,  as  the 
normal  verumontanum  varies  in  size  within  very  wide 
limits;  thus  in  the  colored  race,  for  instance,  the  normal 
verumontanum  is  usually  of  very  large  dimensions,  corre- 
sponding to  the  large  size  of  the  entire  sexual  apparatus. 
As  a  general  thing  it  may  be  stated  that  we  must  consider 
the  verumontanum  in  its  relationship  to  the  posterior 
urethra  in  any  particular  individual.  In  other  words,  a 
rather  large-sized  verumontanum  would  not  be  considered 
abnormal  in  an  individual  having  a  very  wide  prostatic 
virethra,  while  a  verumontanum  that  completely  fills  the 
prostatic  urethra,  touching  the  walls  of  the  urethra  on 
either  side,  with  hardly  a  trace  of  a  lateral  sinus  is  to  be 
considered  enlarged.     (See  diagram.) 

As  already  stated,  we  find  congestion  of  the  prostatic 
urethra  in  all  these  cases,  but  this  pathological  picture  may 


230 


Disorders  of  the  Sexual  Function. 


—  -  Lateral  sulcus. 
_ ._  —  UretEral  wall. 


"Verumontanum. 
1.  Normal  verumontanum. 


—  —  Lateral  sulcus. 
—  —  •-  Urethral   wall. 


—  —  Verumontanum. 
2.  Moderately  enlarged  verumontanum. 


—  —Lateral  sulcus. 
—  —  —  Urethral  wall. 


—  —  Lateral  sulcus. 
Urethral  wall. 


—  —  —  Verumontanum.  '  —  —  Verumontanum. 

3.  Very   enlarged  verumontanum.       4.   Atrophic   verumontanum. 


Diagrammatic  pictures  of  normal  and  diseased  verumontanum. 


Withdrawal.  231 


be  brought  about  by  many  other  conditions  than  the  one 
under  consideration.  One  cannot  make  a  diagnosis  of  the 
practice  of  withdrawal  by  merely  looking  through  the 
urethroscope. 

The  pathology  in  the  female  is  similar  to  that  in  the 
male,  but  on  account  of  the  normally  more  passive  part 
taken  by  the  female  during  the  act  of  coitus  the  results 
are  much  less  severe,  though  at  times  we  find  sequelae  just 
as  severe  as  in  the  male. 

In  the  female,  with  the  commencement  of  coitus,  there 
is  a  general  hyperemia  of  all  the  pelvic  organs.  In  a  nor- 
mal coitus  with  fully  developed  orgasm,  and  the  expulsion 
of  the  secretions  from  the  genital  glands,  a  deplethorization 
occurs,  and  the  organs  are  left  in  their  natural  condition. 
If,  however,  the  act  is  interrupted  by  withdrawal  on  the 
part  of  the  husband,  the  orgasm  either  does  not  take  place 
at  all,  or  takes  place  incompletely,  the  sexual  glands  do 
not  completely  empty  themselves, — in  other  words,  the 
female  does  not  really  "come";  the  pelvic  organs  remain 
hyperemic  and,  after  this  state  of  affairs  has  continued  for 
a  time,  a  condition  of  chronic  congestion  of  the  pelvic 
organs  takes  place,  with  all  its  disastrous  results. 

It  should  be  mentioned  that,  in  even  so-called  normal 
coitus,  the  woman  does  not  receive  the  consideration  she 
deserves  in  a  vast  majority  of  cases.  From  a  very  large 
clinical  experience  and  study,  I  have  come  to  the  conclu- 
sion that  probably  not  one  of  five  men  know  how  to  per- 
form the  sexual  act  correctly.  As  a  general  thing,  even 
in  so-called  normal  coitus,  the  man  only  considers  himself 
and  not  the  woman  at  all.     We  find  that  when  the  desire 


232  Disorders  of  the  Sexual  Function. 

for  connection  and  erection  occurs,  he  immediately  goes  at 
it,  whether  the  woman  has  the  desire  or  not,  and  in  many- 
cases  when  she  is  but  half-awakened.  As  soon  as  he  has 
completed  his  part  of  the  act,  he  stops  and  removes  the 
penis.  As  a  result,  at  the  commencement  of  coitus,  the 
woman  is  not  fully  excited,  and  only  becomes  half-way 
excited  during  the  act,  and  remains  excited  because  she  has 
not  nearly  completed  her  part  of  the  act  when  the  husband 
ceases  to  perform. 

In  questioning  many  women  I  have  been  told  that  they 
experience  little  pleasure  during  the  sexual  act,  but  become 
excited  afterward.  Such  women  have  no  real  orgasm  and 
no  perfect  deplethorization.  This  state  of  affairs  has  been 
described  many  years  ago  by  Sturgis,"'^  but  has  not  re- 
ceived the  consideration  it  deserves.  We  see,  therefore, 
that  in  even  so-called  normal  coitus,  in  the  vast  majority 
of  cases,  there  is  left  a  certain  amount  of  congestion  in  the 
female  pelvic  organs, — a  condition  which  becomes  much 
worse  if  the  husband  practises  withdrawal. 

Symptoms. — The  symptoms  may  be  divided  into  local 
and  reflex.  The  sexual  symptoms  have  been  partly  given 
in  discussing  the  pathology.  Briefly  there  is  first  a  state  of 
rapid  ejaculation.  The  patient  notices  that  the  sexual  act 
is  more  rapidly  completed  than  before.  This  condition  of 
overexcitability  increases  in  severity  until  ejaculation  takes 
place  at  the  moment  of  complete  erection  or  even  before  it. 
The  patient  states  that  as  soon  as  his  penis  has  entered, 
ejaculation  takes  place  and  the  whole  thing  is  over  in  a 
moment.  He  consequently  obtains  little  pleasure  from  the 
sexual  act.    Later  on  ejaculation  takes  place  so  rapidly  that 


Withdrawal. 


the  penis  has  no  time  to  enter  the  vagina  (premature  ejacu- 
lation). In  the  final  stage  the  centers  are  completely 
exhausted,  refuse  to  act,  no  ejaculation  takes  place  at  all, 
and  erection  is  either  weak  or  entirely  absent;  in  other 
words,  there  is  complete  impotence,  the  libido  may  be- 
come diminished,  absent,  or  not  at  all  affected.  This  last 
condition  is  particularly  tmpleasant,  as  the  patient  has  nor- 
mal desire,  but  a  complete  lack  of  ability. 

I  desire  again  to  emphasize  the  fact  that  not  every  case 
reaches  this  final  stage,  and  that  the  time  it  takes  to  reach 
any  of  the  conditions  above  enumerated  varies  within  very 
considerable  limits.  In  some  cases  it  is  remarkable  to  note 
the  amount  of  abuse  the  sexual  apparatus  will  stand  before 
it  rebels.  Patients  also  vary  widely  according  as  the  sexual 
or  the  reflex  symptoms  predominate.  Sometimes  frequency 
of  urination  results  on  account  of  the  congestion  of  the 
posterior  urethra. 

Coming  to  the  reflex  symptoms,  we  find  an  entirely  dif- 
ferent state  of  affairs,  and  it  is  more  particularly  to  these 
that  I  would  direct  attention.  The  sexual  symptoms  are 
not  a  source  of  confusion  to  any  great  degree,  because  the 
attention  of  the  physician  is  at  once  directed  to  the  sexual 
apparatus  from  their  very  nature,  and  the  patient  is  treated 
accordingly,  either  by  his  regular  attendant  or  is  referred 
by  him  to  the  specialist.  When,  however,  we  come  to  the 
reflex  symptoms  we  find  them  to  be  of  widely  divergent 
character,  and  many  of  them  do  not  in  any  way  suggest 
their  sexual  origin.  There  is  hardly  an  organ  in  the  body 
whose  workings  may  not  be  disturbed  by  the  reflexes  coming 
from  the  abused  sexual  mechanism.    These  patients  do  not 


234  Disorders  of  the  Sexual  Function. 

come  with  their  symptoms  to  the  genitourinary  speciaHst 
or  to  the  neurologist,  but  to  the  general  practitioner,  the 
orthopedist,  the  gastroenterologist,  the  cardiac  specialist, 
etc.  They  do  not  suspect  the  cause  of  their  trouble,  and 
unless  the  attending  physician  is  on  his  guard  and  con- 
stantly bears  in  mind  the  possibility  of  this  condition  in 
doubtful  cases,  he  may  easily  be  led  astray. 

It  would  take  us  far  beyond  the  limits  of  this  treatise, 
to  enumerate  all  the  symptoms  that  may  be  brought  about 
by  this  condition,  and  which  are  generally  classified  under 
the  general  term  of  "sexual  neurasthenia."  I  will  there- 
fore mention  only  a  few  which  are  very  interesting  or  very 
unusual  types,  and  which  came  under  my  own  personal  ob- 
servation either  in  my  private  practice,  in  the  neurological 
department  of  Dr.  I.  Abrahamson  at  Moimt  Sinai  Dis- 
pensary or  in  my  own  department  of  genitourinary  diseases 
at  Mount  Sinai  Hospital  Dispensary,  and  in  the  Harlem 
Hospital  Dispensary. 

Cardiac  Symptoms  Due  to  Unnatural  Sexual  Practices. 
— Mrs.  X.  came  to  me  complaining  of  a  slight  leucorrhea. 
The  following  history  was  obtained  after  careful  and  tact- 
ful questioning:  She  had  suffered  for  two  years  prior  to 
her  marriage,  about  six  years  ago,  from  marked  cardiac 
palpitation,  together  with  a  ringing  in  the  ears  and  a  feeling 
of  throbbing  in  the  region  of  the  temples.  Believing  she 
had  heart  disease,  she  consulted  several  physicians,  who 
failed  to  give  any  relief.  She  postponed  her  wedding  and 
finally  consulted  a  prominent  internist  in  New  York  City, 
who  found  her  heart  normal  and  prescribed  a  tonic,  but 
this  likewise  did  not  alleviate  the  symptoms.     Finally  she 


Withdrawal.  235 


married,  whereupon  all  her  symptoms  disappeared  and  re- 
mained away  for  about  four  or  five  years,  during  which 
time  she  gave  birth  to  two  children.  Within  the  past  year 
or  two,  however,  all  her  former  symptoms  returned  with 
increased  severity.  This  time  they  were  accompanied  also 
by  marked  swelling  of  both  ankles,  a  morning  edema  under 
both  eyelids,  which  disappeared  during  the  day,  and  by 
urine  of  low  specific  gravity,  with  a  diminution  in  the  per- 
centage of  urea  as  well  as  a  diminution  of  the  total  quantity 
of  urea  passed  in  twenty- four  hours.  The  patient  was  now 
certain  that  she  was  suffering  from  both  heart  disease  and 
kidney  disease. 

A  vaginal  examination  disclosed  a  slight  laceration  of 
the  cervix  and  some  endocervicitis  which  was  sufficient  to 
account  for  the  leucorrhea.  I  was  struck,  however,  with 
the  enlarged  condition  of  the  labia  minora. 

After  careful  and  tactful  interrogation,  she  finally  told 
me  that  she  had  practised  m^asturbation  before  marriage, 
and  on  further  questioning,  she  confessed  that  for  the  last 
few  years  she  had  not  desired  an  increase  in  her  family  and 
had  prevailed  upon  her  husband  to  practice  withdrawal. 
Later  on  she  had  allowed  him  to  have  coitus  only  between 
her  thighs,  not  permitting  any  intromission. 

Considering  this  case  in  retrospect  we  at  once  note  a 
definite  history.  It  is  a  history  of  reflex  cardiac  and  circu- 
latory disturbance  during  masturbation,  followed  by  mar- 
riage with  normal  sexual  relationship  for  several  years, 
during  which  children  were  born  and  during  which  time 
all  the  symptoms  vanished.  This  in  turn  was  followed  by 
a  period  of  abnormal  sexual  relationship,  in  consequence 


236  Disorders  of  the  Sexual  Function. 

of  which,  the  symptoms  immediately  returned  with  increased 
severity.  I  sent  this  patient  to  a  prominent  internist,  tell- 
ing him  of  my  suspicions.  After  careful  examination,  the 
latter  confirmed  my  diagnosis,  finding  the  heart,  kidneys 
and  blood-pressure  normal.  I  explained  the  cause  of  the 
symptoms  to  the  patient  and,  although  she  was  skeptical, 
she  promised  to  follow  instructions,  with  the  result  that 
all  her  symptoms  rapidly  vanished. 

Cases  like  the  above  have  been  described  by  Max  Hertz 
and  others,  but,  as  we  have  seen,  they  are  often  overlooked 
and  in  the  one  just  presented,  the  condition  baffled  the  diag- 
nostic skill  of  many  physicians  as  well  as  that  of  a  prom- 
inent consulting  internist.  Had  this  patient  in  addition 
had  some  real  valvular  lesion  accompanied  by  a  murmur, 
it  can  be  readily  understood  how  much  more  obscure  the 
case  would  have  been  and  how  easily  all  her  symptoms 
might  have  been  ascribed  to  a  cardiac  condition. 

Symptoms  of  Sciatica  Due  to  the  Practice  of  With- 
drawal.— Although  this  case  has  been  reported  by  me  else- 
where,^^ it  is  such  an  unusual  type,  that  I  feel  justified  in 
repeating  it  here. 

The  patient,  A.  W.,  a  painter,  had  been  treated  at 
various  neurological  clinics  for  over  a  year  for  sciatica  of 
the  left  side.  He  had  had  the  usual  treatment.  His  pre- 
vious history  is  briefly  as  follows :  Patient  complains  of 
pains  in  the  left  lower  extremity;  is  excitable;  has  severe 
tenderness  in  the  left  sacroiliac  joint.  He  was  treated  by 
electricity,  including  the  high-frequency  current,  hot  air,  hot 
baths,  as  well  as  iodide  of  potassium,  but  all  without  avail. 
He  finally  had  to  stop  working  at  his  trade,  as  he  could 


Withdrawal.  237 

not  climb  ladders   or  work  on  scaffolding.      His  general 
condition  was  poor  and  he  looked  much  emaciated.     He 
was  then  referred  to  me  for  examination.     I   found  the 
prostate  enlarged  and  tender;  but  especially  the  left  seminal 
vesicle  (the  side  of  the  sciatica)  was  very  much  enlarged 
and  nodular.     This,  with  his  emaciated  condition,  and  in 
the  absence  of  a  history  of  gonorrhea,  made  me  suspect 
tuberculosis.     However,   an  examination  of  the  secretion 
of  his  vesicles  and  prostate  obtained  by  massage,  as  well  as 
his  urine,  failed  to  show  any  tubercle  bacilli.    I  cystoscoped 
him  also,  and  found  his  bladder  normal.     I  treated  him 
by  massage  of  the  prostate  and  seminal  vesicles,  at  first 
once  a  week  and  later-  every  other  week.     After  six  treat- 
ments he  felt  much  better,  and  after  ten  treatments  was 
entirely  cured  and  could  do  all  the  work  necessary  in  his 
trade.     The  local  condition  of  his  prostate  and   seminal 
vesicles   also  became   normal,    and   his   general   condition 
markedly  improved. 

In  this  case  it  must  be  borne  in  mind  that  there  had 
been  absolutely  no  improvement  for  over  a  year,  and  that 
while  under  my  care  the  patient  received  absolutely  no 
treatment,  medical  or  otherwise,  except  massage  of  the 
prostate  and  vesicles.  The  etiological  cause  in  this  case 
was  the  practice  of  withdrawal,  of  which,  however,  the 
patient  made  no  mention  in  giving  his  history,  not  thinking 
that  it  had  anything  to  do  with  his  condition.  This  case 
recalls  to  my  mind  the  good  results  obtained  by  Fuller  in 
the  treatment  of  chronic  arthritis  (even  in  non-gonorrheal 
cases)  by  drainage  of  the  seminal  vesicles. 

Nervous  Exhaustibility  Due  to  Withdrawal— Th\s  is  a 


238  Disorders  of  the  Sexual  Function. 

very  common  condition  and  is  merely  inserted  to  illustrate 
a  common  t3^pe  of  sexual  neurasthenia:  M.  L,,  aged  39, 
married,  but  separated  from  his  wife;  complains  of  loss  of 
memory,  lack  of  concentration  of  interest,  and  other  gen- 
eral nervous  complaints.  These  symptoms  are  common  to 
the  most  diverse  nervous  conditions,  and  it  was  only  after 
more  minute  interrogation  that  the  following  important 
facts  were  brought  out  in  the  patient's  sexual  history,  which 
contained  the  clue  to  the  etiology,  and  to  which  the  patient 
in  the  first  instance  attached  little  importance.  It  was 
elicited  that  the  patient  had  lost  all  sexual  desire  and  that 
for  some  time  previous  to  his  separation  he  had  practised 
withdrawal.  Upon  examination,  a  very  enlarged  and  tender 
prostate  gland  was  found,  and  the  posterior  urethroscope 
showed  a  remarkably  congested  prostatic  urethra. 

Patient  was  treated  by  massage  of  the  prostate  and  by 
the  application  of  10^  silver  nitrate  to  his  verumontanum 
through  the  urethroscope. 

The  improvement  was  very  gratifying  and  very  rapid. 
After  a  few  treatm.ents  the  patient  himself  remarked  that 
he  was  regaining  his  former  energy. 

As  stated  at  the  beginning  of  this  chapter,  the  etiology 
might  seem  very  easy  when  read  in  connection  with  the 
diagnosis  placed  at  the  head  of  the  history,  but  it  is  a  far 
different  state  of  affairs  when  the  patient  attends  the 
neurological  clinic,  mingling  with  many  organic  and  func- 
tional nervous  cases,  giving  no  sexual  history  of  himself 
except  such  as  is  painstakingly  elicited  by  the  examiner. 

Pain  in  Skin  of  Penis,  Complete  Impotence  and  General 
Neurasthenia  Due  to  Withdrawal — This  patient  came  to 


Withdrawal.  239 


the  dispensary  complaining  only  of  severe  pain  in  the  skin 
covering  the  penis,  without  urethral  pain;  further  investi- 
gation of  his  history,  however,  brought  out  the  fact  that 
he  had  reached  the  final  stage  of  impotence,  with  complete 
exhaustion  of  both  the  erection  and  the  ejaculation  centers 
due  to  withdrawal. 

D.  D.,  male,  age  45 ;  married  eighteen  years ;  father  of 
4  children;  last  child  born  eighteen  months  ago;  came  into 
my  clinic  at  Mt,  Sinai  Hospital  Dispensary,  complaining 
only  of  severe  pain  in  the  skin  of  the  penis.  The  pain  was 
strictly  limited  to  the  penile  integument,  and  did  not  at 
all  affect  the  perineal  integument.  The  patient  also  com- 
plained of  vague  pains  in  the  abdominal  region.  He  had 
no  pains  whatever  in  the  urethra  and  no  pains  connected 
with  urination.  He  gave  a  doubtful  history  of  urethritis 
ten  years  earlier,  but  did  not  remember  whether  he  had 
any  urethral  discharge  at  that  time.  Endoscopy  of  the 
anterior  urethra  showed  a  normal  urethra  with  several  con- 
gested follicles.  His  meatus  was  too  small  for  posterior 
urethroscopy,  and  the  patient  objected  to  meatotomy. 

Investigating  his  history  more  minutely,  the  following 
facts  were  disclosed.  He  has  been  absolutely  impotent  for 
tw^o  years  past,  and  can  neither  have  an  erection  or  ejacu- 
lation. Previous  to  this,  he  had  suffered  for  about  six 
years  from  rapid  ejaculation  and  feeble  erections,  which 
constantly  became  more  and  more  feeble  until  the  present 
state  of  impotence  ensued.  This  condition  of  feeble  erec- 
tion and  rapid  ejaculation  did  not  prevent  him  however, 
from  impregnating  his  wife,  who  gave  birth  to  a  child 
eighteen  months  ago.     About  eight  years  ago,  and  while 


240  Disorders  of  the  Sexual  Function. 

still  sexually  active,  he  had  suffered  from  frequent  noc- 
turnal pollutions,  at  least  once  every  night  and  somtimes 
two  or  three  a  night.  In  fact,  he  even  suffered  from 
pollutions  when  indulging  in  coitus.  For  the  past  four 
years  he  has  not  had  any  wet  dreams  whatever,  even 
though  he  has  had  no  coitus  at  all  for  two  years.  The 
patient  admitted  to  having  practised  withdrawal  for  four 
years,  starting  about  eight  years  ago.  Besides  the  urethral 
findings  just  mentioned  the  examination  revealed  a  slight 
mitral  murmur,  abdomen  negative,  slightly  enlarged  axil- 
lary, cervical  and  inguinal  glands.  His  prostate  is  moder- 
ately enlarged. 

In  this  case,  besides  the  general  neurasthenic  symptoms, 
we  have  elicited  from  the  patient  a  perfect  history  of  the 
course  of  events  consequent  upon  withdrawal.  This  is  an 
extreme  case.  It  presents  a  history  of  withdrawal  for  a 
period  of  four  3'ears.  At  first  erection  and  ejaculation  are 
good,  but  the  patient  suffers  from  frequent  pollutions 
(overexcitability  of  the  ejaculation  center).  This  is  fol- 
lowed by  a  history  of  gradually  weaker  and  weaker  erec- 
tions, together  with  rapid  ejaculation  (extreme  excitability 
of  ejaculation  center,  with  gradual  weakness  of  erection 
center).  Finally,  there  is  neither  erection  nor  ejaculation, 
nor  are  there  even  wet  dreams.  In  other  words  there  has 
been  a  complete  paralysis  or  exhaustion  of  both  the  ejacu- 
lation and  erection  centers.  These  facts  may  be  translated 
into  pathological  parlance  as  follows :  The  erection  center 
is  being  continually  bombarded  by  reflex  stimulation,  due 
both  to  the  distention  of  the  seminal  vesicles  caused  by 
incomplete  emptying,  and  to  the  chronic  congestion  of  the 


Withdrawal.  241 


deep  urethra,  due  to  withdrawal.  As  a  result,  impulses  are 
being  continually  sent  to  the  ejaculation  centers  until  the 
latter  becomes  so  hyperirritable  that  at  night,  when  the 
inhibitor}'  influences  of  the  cerebrum  are  lacking,  the  slight- 
est additional  stimulation  such  as  the  heat  of  the  bedding, 
etc.,  is  sufficient  to  bring  on  erection  and  ejaculation  (i.  e., 
numerous  wet  dreams).  As  the  disease  progresses  the 
erection  center  finally  becomes  so  extremely  hyperirritable 
during  coitus,  that  it  sends  impulses  to  the  ejaculation  cen- 
ters even  before  it  is  completely  filled  up  with  impulses 
from  the  glans  penis,  the  seminal  vesicles  and  the  cerebrum 
(see  Fig.  4,  page  67).  In  other  words,  the  erection  center 
has  lost  its  function  of  holding  back  these  impulses  until  the 
proper  time,  and  the  condition  of  rapid  ejaculation  is  the 
natural  sequence.  Finally,  both  the  erection  center  as  well 
as  the  ejaculation  centers  become  completely  exhausted  and 
no  longer  respond  to  any  stimulation  from  the  penis,  sem- 
inal vesicles,  or  the  cerebrum,  no  matter  how  strong  such 
stimuli  may  be.  When  that  stage  is  reached  there  is  neither 
erection  nor  ejaculation;  the  patient  is  absolutely  impotent 
and  cannot  even  have  a  wet  dream. 

Gastrointestinal  Symptoms  and  Impotence  Due  to  With- 
drawal.— A.  R.,  referred  to  me  by  Dr.  Abrahamson  in  May, 
19 1 3,  was  55  years  old,  married  twenty  years,  and  the 
father  of  7  children,  his  last  child  having  been  born  seven 
years  ago.  It  may  be  stated  in  passing  that  in  order  to 
obtain  a  confession  of  withdrawal  from  some  of  these  pa- 
tients I  inquire,  as  a  routine  procedure,  for  the  date  of  the 
birth  of  the  last  child  or  the  date  of  the  last  miscarriage. 
If  it  appears  that  many  years  have  elapsed  since  the  last 

16 


242  Disorders  of  the  Sexual  Function. 

pregnancy,  I  ask  why  his  wife  has  not  become  pregnant  in 
so  long  a  time,  and  directly  suggest  withdrawal  as  the 
probable  cause.  The  patient,  thus  taken  off  his  guard,  gen- 
erally confesses  to  the  practice,  whereas  he  would  probably 
have  denied  it  if  questioned  directly. 

This  patient  complained  of  belching,  of  regurgitation 
of  food,  and  of  vomiting.  Upon  further  questioning  he 
also  complained  of  seminal  losses  during  defecation,  and 
of  impotence  for  five  years  past.  He  admitted  to  practising 
withdrawal  for  the  past  seven  years. 

On  account  of  his  age  and  very  emaciated  appearance, 
I  did  not  feel  justified  in  ascribing  his  gastrointestinal 
symptoms  to  withdrawal  until  I  had  had  him  examined  by 
an  internist  for  possible  carcinoma  or  other  gastrointestinal 
disorder.  However,  the  internist  found  the  gastrointestinal 
tract  practically  normal,  and  I  thereupon  instituted  a  course 
of  treatment  to  be  hereinafter  described,  which  had  the 
result  that  after  two  months  the  patient  was  able  not  only 
to  have  normal  coitus  for  the  first  time  in  five  years,  but 
that  all  his  gastrointestinal  symptoms  left  him,  he  gained 
in  weight,  and  again  felt  in  perfect  condition. 

Diagnosis. — The  diagnosis  can  only  be  made  by  bearing 
in  mind  the  possibility  of  such  an  etiological  factor  in  con- 
ditions otherwise  obscure.  One  often  has  to  be  very  tact- 
ful in  order  to  elicit  a  confession  of  this  practice,  especially 
in  interrogating  the  female.  It  is  often  useless  to  ask 
either  party  directly  whether  they  indulge  in  It,  as  they 
may  often  deny  it.  As  a  practical  point,  I  have  found  it 
expedient  to  catch  the  patient  off  his  (or  her)  guard,  either 
before  or  after  examination.     I  inquire,   in  my  routine 


244  Disorders  of  the  Sexual  Function. 

coitus  increase  until  the  normal  is  reached.  The  patient 
must  be  told  that  his  first  attempts  will  naturally  be  weaker 
than  normal,  and  must  be  assured  that  in  a  little  while 
they  will  become  entirely  normal.  At  this  stage  he  must 
also  be  cautioned  not  to  abuse  his  newly  developed  power, 
but  to  have  coitus  at  rather  long  intervals  for  a  while,  and 
only  when  he  has  strong  desire.  He  should  be  cautioned 
particularly  against  experimenting  himself,  by  making  at- 
tempts at  coitus  without  any  desire  at  all,  simply  to  see 
if  he  can  effect  it.  In  those  cases  which  were  characterized 
at  first  by  the  presence  of  frequent  pollutions  and  later  on 
by  an  entire  absence  of  all  pollutions,  there  may  be  a  reap- 
pearance of  the  pollutions  while  they  are  progressing 
toward  recovery,  before  the  final  normal  state  is  reached. 
This  phenomenon  often  discourages  the  patient  but,  again, 
it  is  a  sign  of  improvement,  as  it  shows  that  the  sexual 
centers,  previously  completely  paralyzed,  are  now  again 
beginning  to  respond  to  peripheral  impulses.  Whenever 
this  occurs,  it  is  an  indication  to  omit  massage  of  the  pros- 
tate if  it  has  been  employed.  As  already  indicated,  the 
prognosis  is  excellent  in  most  cases. 

Treatment. — The  treatment  of  this  condition  is  both 
rational  and  simple,  and  the  results  are  correspondingly 
gratifying.  Nothing  is  more  easy  to  treat  than  impotence 
caused  by  withdrawal.  Incidentally  it  may  be  stated  that, 
despite  the  popular  opinion  to  the  contrary,  impotence  as 
a  general  thing  is  very  easy  to  treat  and  very  easy  to  cure, 
if  we  know  the  etiological  factor  or  the  pathological  lesion 
underlying  the  condition.  Impotence  is  but  a  symptom, 
and  to  treat  it  as  if  it  were  a  disease,  or  a  distinct  entity, 


Withdrawal.  245 


is  a  serious  error,  and  is  nothing  more  or  less  than  guess- 
work. 

As  has  been  pointed  out  in  discussing  the  pathology  of 
withdrawal,  there  is  at  first  increased  irritability,  and  later 
on  an  exhaustion  of  the  erection  and  ejaculatory  centers, 
together  with  a  congestion  of  the  entire  prostatic  urethra. 
In  the  female  almost  all  the  symptoms  are  reflex,  but  some 
of  these  may  be  explained  by  the  chronic  congestion  of  the 
pelvic  organs.  Owing  to  the  more  passive  part  taken  by 
the  female  during  coitus,  the  symptoms  are  not  so  pro- 
nounced, and  are  often  absent  altogether.  Inasmuch  as 
even  in  the  case  of  the  female,  the  cause  of  the  condition 
is  due  to  the  male,  there  is  no  special  treatment  for  the 
female  except  the  giving  of  advice  for  her  partner. 

The  first  thing  to  be  done  is  to  bring  about  a  condition 
of  sexual  rest.  This  means,  not  only  abstaining  from  coitus, 
but  abstaining  from  anything  that  may  reflexly  or  other- 
wise irritate  the  sexual  centers.  The  couple  should  not 
sleep  in  the  same  bed ;  they  should  avoid  spooning,  hugging, 
kissing,  etc.  Strict  and  explicit  instruction  should  be  given 
on  this  point,  for  miany  patients  believe  that  they  may  do 
almost  anything,  so  long  as  they  abstain  from  coitus.  As 
a  matter  of  fact,  however,  I  would  much  rather  have  a 
married  man  perform  coitus  than  have  him  excite  himself 
into  an  erotic  condition  by  spooning,  etc.,  and  then  stop. 
As  stated  above,  there  must  be  absolutely  no  sexual  excite- 
ment of  any  kind  whatsoever. 

In  reading  the  histories  of  some  of  the  cases  cited,  the 
reader  may  have  noticed  that  in  many  of  them  the  symp- 
toms did  not  come  on  immediately  after  the  commencement 


246  Disorders  of  the  Sexual  Function. 

of  the  pernicious  practice,  but  some  time  afterward,  per- 
haps even  at  a  time  when  the  practice  had  been  given  up 
and  normal  coitus  was  being  induged  in.  In  many  such 
cases  it  is  hard  to  make  the  patients  understand  that  the 
previous  withdrawal  is  responsible  for  their  symptoms. 
Their  answer  is  that  they  felt  all  right  while  indulging  in 
the  practice,  but  have  been  feeling  badly  only  now  when 
they  are  having  normal  coitus.  Nevertheless,  the  pathology 
is  clear  and  the  symptoms  are  easily  explicable.  The  cen- 
ters in  these  cases  have  begun  to  become  hyperirritable, 
and  the  prostatic  urethra  has  just  commenced  to  become 
congested,  so  that  even  the  additional  excitement  of  the 
centers  during  normal  coitus,  or  the  additional  hyperemia 
of  the  prostatic  mucous  membrane  of  normal  coitus,  is  an 
irritation  which,  if  continued,  will  still  further  increase  the 
pathological  condition  and  symptoms,  or  will  bring  forth 
symptoms  if  none  have  previously  existed.  It  is  for  this 
reason  that  absolute  sexual  rest  (which  means,  not  even 
normal  coitus)  is  so  essential.  How  long  this  period  of 
rest  is  to  continue  varies  with  each  individual.  It  depends 
upon  the  stage  of  the  disease  and  the  sexual  habits  of  the 
patient.  At  least  two  months'  rest  is  generally  necessary, 
and  in  many  cases  four  to  six  months'  rest  is  not  too  long. 
If  the  patient  can  be  sexually  separated  from  his  wife  for 
a  time,  it  is,  of  course,  much  better.  The  wife  should  be 
instructed,  if  possible,  as  well  as  the  husband;  for,  other- 
wise, if  she  be  kept  in  ignorance,  she  may  counteract  the 
treatment  by  insisting  on  connection,  if  she  be  at  all  a  pas- 
sionate woman.  Many  of  the  good  results  achieved  in 
Germany,  by  sending  the  husband  to  some  particular  *'kur" 


Withdrawal  247 


place,  are  not  due  to  drinking  the  waters  at  all;  nor  solely 
to  the  hydrotherapeutic  measures  employed  (although  these 
are  of  value),  but  to  the  enforced  continence,  and  to  keep- 
ing the  patient's  mind  occupied,  and  away  from  sexual 
thoughts.  Of  course,  each  case  is  a  law  unto  itself,  and  the 
physician  must  take  into  consideration  the  sexual  character- 
istics of  the  particular  patient,  particularly  guarding  against 
the  likelihood  of  the  patient  indulging  in  extramarital  coitus 
if  kept  away  from  his  wife  for  too  long  a  time. 

The  next  indication  is  to  reduce  the  hyperirritability  of 
the  sexual  centers.  For  this  purpose  nothing  is  so  useful 
as  the  bromides,  which  must  be  given  in  fairly  large  doses. 
I  generally  start  with  15  grains  of  sodium  bromide  four 
times  a  day,  taken  in  sweetened  water,  half  an  hour  after 
meals  and  just  before  going  to  bed.  Later,  I  reduce  this 
to  three  times,  twice,  or  once  a  day.  Besides  having  the 
effect  of  diminishing  the  excitability  of  the  sexual  centers, 
the  bromides  have  the  additional  advantage  of  greatly 
reducing,  and  in  many  instances  taking  away  for  the  time 
being,  all  sexual  desire.  This  greatly  conduces  toward 
continence,  which  is  so  essential  to  the  treatment.  It  is  also 
necessary  to  explain  to  patients  who  come  for  treatment 
for  impotence,  due  to  withdrawal,  just  what  we  are  trying 
to  accomplish,  and  what  the  effect  of  the  medication  will 
be;  otherwise  they  will  complain  that  they  are  worse  off 
during  the  treatment  than  before,  having  now  lost  all  desire 
as  well  as  potency.  This  reduction  of  desire  is  only  tem- 
porary, however,  and  I  have  never  seen  any  permanent 
harm  to  the  sexual  apparatus  due  to  the  proper  use  of 
bromides, — at  least,  for  the  length  of  time  that  it  is  neces- 


248  Disorders  of  the  Sexual  Function. 

sary  to  employ  them  in  the  condition  under  consideration. 
Another  great  advantage  of  the  bromides  is  the  almost 
immediate  amelioration  of  nocturnal  pollutions.  In  order 
to  further  suppress  the  irritability  of  the  centers,  it  is  best 
to  avoid  all  alcoholics,  as  well  as  tea,  coffee,  eggs,  and 
oysters,  all  of  which  stimulate  sexual  desire. 

The  next  indication  is  to  reduce  the  congestion  of  the 
prostate  and  prostatic  urethra,  for  as  long  as  these  remain 
congested  they  are  continually  sending  erotic  impulses  to 
the  sexual  centers  in  the  spinal  cord  as  well  as  to  the  cere- 
brum. To  accomplish  this,  nothing  succeeds  so  well  as 
the  application  of  silver-nitrate  solution  to  the  affected 
parts,  and  in  some  cases  massage  of  the  prostate.  At  first, 
when  the  congestion  is  intense,  we  should  start  with  a  very 
weak  solution  (i :  3000)  instilled  very  gently  with  a  small- 
size  Bangs  sound  syringe.  As  the  case  progresses  the  solu- 
tion should  be  increased  up  to  i :  500.  The  sound  syringe 
used  should  be  larger  and  larger  until  the  capacity  of  the 
meatus  for  sounds  is  reached.  All  manipulations  in  the 
urethra  must  be  done  slowly  and  gently,  while  the  instilla- 
tions should  not  be  given  oftener  than  once  every  fifth  day, 
and  less  often  later  on.  In  many  cases  this  is  all  that  is 
necessary  to  bring  the  mucous  membrane  back  to  its  nor- 
mal condition.  In  some  particularly  bad  cases  of  impotence, 
however,  w^e  may  have  to  employ  something  more  stimu- 
lating to  the  mucous  membrane,  toward  the  end  of  the 
treatment,  and  when  we  have  stopped  the  sedative  medica- 
tion and  are  employing  stimulating  treatment  to  be  de- 
scribed hereafter.  In  this  condition  nothing  acts  so  well 
as  the  local  application  of  10^   silver  nitrate  to  the  ve- 


Withdrawal  249 


rumontanum  through  the  AVossidlo-Goldschmidt  posterior 
urethroscope.  To  those  Avho  have  neA-er  used  this  instru- 
ment, it  will  be  a  revelation  how  clearly  we  can  see  the 
verumontanum  and  its  adjacent  structures,  how  distinctly 
we  can  recognize  any  pathological  condition  of  these  parts, 
and,  particularly,  how  easily  and  accurately  we  can  make 
an  application  to  whatever  spot  we  desire.  It  may  be  well 
to  emphasize  that  it  is  not  in  every  case  that  we  need  to 
make  a  direct  application,  but  only  in  obstinate  cases  of 
impotence,  and  in  these  it  is  certainly  most  effective.  These 
strong  applications  should  not  be  made  more  often  than 
once  a  week  at  the  utmost,  and  should  be  made  only  at  a 
time  when  the  acute  congestion  has  been  substantially 
removed  by  the  previous  instillation  treatment. 

As  regards  massage  of  the  prostate,  this  is  an  excellent 
procedure,  but  it  has  its  limitations.  ]\Iuch  harm  may  be 
done  by  it,  if  used  at  the  wrong  time,  or  in  the  wrong 
manner.  Massage  of  the  prostate  shoidd  never  he  employed 
zuhen  the  patient  is  suffering  from  frequent  pollutions,  and 
should  be  stopped  whenever,  in  the  course  of  treatment, 
pollutions  become  frequent.  In  other  words,  in  many  cases 
originally  uncomplicated  by  pollutions,  and  where  massage 
is  proper,  the  massage  sometimes  brings  on  pollutions,  and 
in  other  cases  it  increases  their  number.  Where  this  is  the 
result,  however,  it  should  be  discontinued  at  once. 

The  method  of  massage  to  be  employed  is  likewise  of 
the  utmost  importance.  It  is  unfortunate  that  every 
manipulation  of  the  prostate  per  rectum  is  described  as 
"massage,"  whereas  a  distinction  should  be  made  between 
expression  and  massage.     To  illustrate:  In  certain  forms 


250  Disorders  of  the  Sexual  Function. 


of  chronic  gonorrhea,  where  either  for  diagnosis  or  treat- 
ment we  are  trying  to  rid  the  prostate  of  gonococci,  it  may 
be  necessary  and  justifiable  to  employ  considerable  pressure 
in  order  to  squeeze  out  the  secretions  of  the  gland,  as  well 
as  those  of  the  seminal  vesicles,  and  even  here  caution  is 
necessary.  In  the  condition  under  consideration,  however, 
our  object  is  not  to  squeeze  out  the  last  drop  of  pus  from 
the  follicles,  but  to  relieve  congestion.  Here  it  is  necessary 
to  perform  "massage"  in  the  strict  sense  of  the  word.  A 
hard  and  painful  squeezing  of  the  parts  can  no  more  be 
called  "massage"  than  giving  a  man  a  severe  punch  in  the 
stomach  can  be  called  massage  of  the  stomach.  We  must 
remember  that  the  parts  are  congested  and  tender,  and  that 
our  manipulations  must  therefore  be  exceedingly  gentle  and 
of  very  short  duration.  As  the  case  improves  we  may  use 
firmer  and  f^rrrier  pressure,  of  longer  and  longer  duration. 
Done  in  this  way,  and  within  the  limitations  outlined  above, 
massage  of  the  prostate  is  an  exceedingly  useful  adjunct  to 
the  treatment. 

As  the  patient  improves,  the  bromides  are  gradually 
withdrawn  and  the  limitations  in  diet  are  removed  little  by 
little.  If  impotence  is  the  main  symptom,  we  now  employ 
stimulating  measures,  and  for  this  purpose  nothing  acts 
better  than  strychnine  nitrate,  given  in  fairly  large  dosesi 
just  before  the  expected  coitus.  This  has  no  effect  upon 
the  sexual  desire,  but  if  the  desire  is  present  it  has  the 
effect  of  making  the  penis  erect  and  firm. 

Besides  the  prohibition  of  the  practice,  our  treatment 
in  brief  is  as  follows :  The  patient  is  given  instructions 
both  as  to  continence  and  diet.     At  first  he  is  given  15 


Withdrawal.  251 


grains  of  sodium  bromide  four  times  a  day,  which  is  gradu- 
ally reduced.  Every  fifth  day,  and  less  often  later  on,  he 
is  given  a  deep  urethral  instillation  of  silver  nitrate  in 
gradually  increasing  strengths,  together  with  proper  mas- 
sage of  the  prostate.  Still  later,  direct  applications  of 
strong  silver  nitrate  to  the  verumontanum  region  through 
the  posterior  endoscope  may  be  necessary.  The  limitations 
as  to  diet  are  gradually  removed,  the  bromides  reduced  in 
frequency  and  finally  stopped  altogether,  while  strychnine 
nitrate  is  given  for  impotence  if  it  exists. 

It  w^ill  be  noticed  that  no  mention  has  been  made  of 
electricity  or  any  other  form  of  psychic  treatment,  for  I 
cannot  state  too  emphatically  that  the  results  of  withdrawal 
are  entirely  pathological,  and  not  merely  imaginary.  The 
lesions  actually  do  exist,  and  the  pathological  condition  in 
the  urethra  can  actually  be  seen.  The  results  of  the  treat- 
ment can  be  more  readily  appreciated  by  looking  through 
the  endoscope  and  noting  the  condition  of  the  prostate.  To 
tell  a  man  who  is  impotent  from  withdrawal  that  he  is 
merely  imagining  his  condition,  is  to  court  well-deserved 
ridicule.  The  treatment  as  I  have  endeavored  to  describe 
it,  is  based  upon  a  rational  understanding  of  the  pathology 
of  the  condition,  and  the  results  are  exceedingly  gratifying. 


CHAPTER  XVII. 

CONTINENCE. 

General  considerations.  Importance  to  general  practitioner  and 
every  specialty.  Social  and  economic  considerations.  Prevention  of 
spread  of  venereal  disease.  Prophylactic  treatment  of  venereal  dis- 
ease. Chances  of  infection  from  illicit  coitus.  Abortive  treatment 
of  venereal  disease.  Is  continence  physiological?  Views  of  physiolo- 
gists. Views  of  various  authors.  Masturbation  and  continence.  Sexual 
perversion  due  to  continence.  Author's  opinions.  Views  of  neurol- 
ogists. Continence  and  impotence.  Coitus  not  merely  for  purposes 
of  procreation.  Continence  contrary  to  nature.  Author's  deductions. 
Improvement  in  morality  as  compared  to  the  past. 

The  subject  of  continence  is  one  of  vital  importance, 
not  only  to  the  genitourinary  specialist  and  neurologist, 
but  to  every  specialist  and  general  practitioner,  for  what 
organ  or  function  of  the  body  is  there  which  has  not  been 
attacked  by,  or  is  immune  to,  the  ravages  of  syphilis  ?  And 
yet,  how  neglected  is  this  important  subject!  Examine 
our  standard  textbooks  on  venereal  diseases,  and  while  you 
will  find  therein  elaborate  discussions  of  the  evil  effects  of 
non-continence,  in  how  many  of  them  is  there  a  chapter 
on  continence.  Several  vears  ago  I  examined  most  of  the 
standard  textbooks  on  physiology  written  in  the  English 
language,  and  could  find  practically  no  reference  whatever 
nor  any  information  as  to  whether  continence  is  physiologi- 
cal or  not.  The  absence  of  reference  to  continence  in  works 
devoted  to  venereal  diseases  is  a  positive  defect  in  such 
works.  The  gastroenterologist  not  only  cures  his  patient 
of  his  present  attack  of  indigestion,  but  also  gives  him 
instructions  about  his  diet  and  mode  of  living  in  order  to 
(252) 


Continence.  253 


avoid  future  attacks  as  well.  The  cardiac  specialist  not 
only  relieves  his  patient  of  his  disturbed  compensation,  but 
instructs  him  most  minutely  how  to  conduct  himself  in  the 
future  in  order  to  prevent  future  decompensations,  if  pos- 
sible. He  would  indeed  be  a  poor  phthisisist  who  would 
not  inform  his  cured  consumptive  patient  how  to  live  there- 
after in  order  to  remain  well.  Why  then  should  the  genito- 
urinary specialist,  after  having  cured  his  patient's  first  gon- 
orrhea, not  warn  him  how  to  conduct  himself  in  the  future 
in  order  to  prevent  more  serious  trouble? 

It  is  about  six  years  ago  that  P^  wrote  upon  this  sub- 
ject in  connection  with  prophylaxis  in  gonorrhea.  In  that 
article  I  blamed  the  medical  profession  for  much  of  the 
spread  of  venereal  disease.  I  also  cited  cases  to  prove  my 
formula,  that  illicit  connection  equals  venereal  disease. 

Great  strides  have  taken  place  in  medicine  since  that 
time.  The  Wassermann  reaction  and  the  complement- 
fixation  test  for  gonorrhea  have  confirmed  our  suspicions, 
and  have  still  further  emphasized  the  terrible  consequences 
of  both  syphilis  and  gonorrhea,  and  the  relationship,  hitherto 
merely  suspected,  of  these  diseases  to  incurable  conditions 
of  many  vital  organs.  The  public  press  and  the  stage  have 
brought  home  to  the  lay  public,  in  no  uncertain  language, 
the  possible  consequences  of  illicit  coitus.  Our  young 
women  have  become  enlightened  in  these  matters,  and  sex 
education  is  the  order  of  the  day.  They  are  no  longer 
willing  to  allow  their  genitals  to  be  made  a  culture  medium 
for  the  gonococcus  and  Spirochccta  pallida.  They  refuse 
to  be  deprived  of  the  pleasures  of  motherhood  or  of  only 
bringing  into  the  world  children  deformed  or  otherwise 


254  Disorders  of  the  Sexual  Function. 

handicapped  with  the  ravages  of  congenital  S3'phiHs.  They 
object  to  being  castrated  or  spending  a  Hfe  of  misery  in 
return  for  the  privilege  of  exchanging  "]\Iiss''  for  "Mrs." 

Side  by  side  with  this  enlightenment  of  the  public  on 
sexual  matters,  another  factor  has  made  itself  felt  for  some 
time,  and  that  is  the  social-economic  factor.  This  is  no 
new  influence,  though  it  is  more  keenly  experienced  today, 
perhaps,  than  ever  before.  With  the  underlying  causes  of 
this  factor,  we,  as  physicians,  cannot  concern  ourselves;  it 
belongs  to  the  domain  of  political  economy  rather  than  to 
that  of  medicine.  But,  whatever  the  cause,  the  results 
stare  us  in  the  face,  and  serve  to  bring  the  question  of  con- 
tinence into  prominence  all  the  more.  As  a  result  of  the 
greater  number  of  conveniences  which  the  average  person 
now  enjoys,  the  better  housing,  the  more  skillful  medical 
attention,  the  greater  number  of  luxuries  of  the  average 
person  today,  compared  to  many  years  ago,  when  people 
were  content  to  live  in  rear  tenements,  and  when  even  the 
better-class  apartments  coidd  not  compare  in  convenience 
with  those  of  today — as  a  result  of  all  this,  and  of  many 
other  social  economic  factors  too  numerous  and  complicated 
to  discuss,  the  relative  cost  of  living  is  far  greater  now  than 
heretofore,  and  the  young  man  cannot  enter  matrimony  at 
as  early  an  age  as  he  could  fifty  or  a  hundred  years  ago. 
If  he  expects  to  live  in  merely  fair  comfort,  and  to  give  his 
prospective  children  the  benefits  of  modern  education,  he 
must  defer  his  marriage  until  his  income  is  far  in  excess 
of  that  which  his  grandfather  or  even  his  father  had  when 
they  were  married. 

We  have  therefore  the  following  three  alternatives: — 


Continence.  255 

1.  Illicit  coitus  equals  venereal  infection. 

2.  The  modern  girl  refuses  to  marry  a  man  infected 
with  venereal  disease. 

3.  Social-economic  conditions  prevent  early  marriage. 
We,  as  physicians,  cannot  alter  the  third  condition,  for 

we  can  neither  reduce  the  cost  of  living  nor  increase  wages. 
Likewise,  we  cannot  alter  the  second  condition,  for  we  may 
not  say  to  the  modern  girl  "You  must  marry  an  infected 
man" ;  nor  Avould  we  if  we  could. 

It  is,  therefore,  only  with  the  first  proposition  that  we, 
as  physicians,  have  to  deal.  Wt  are  confronted  with  the 
condition,  that  a  man  cannot  marry  as  soon  as  his  sexual 
organs  are  ripe,  that  if  he  has  illicit  connection,  he  becomes 
infected  with  A'enereal  disease,  and  that  if  he  becomes 
infected  and  is  not  cured  he  cannot  get  married.  How, 
then,  shall  we  meet  this  problem? 

I  desire  to  state  at  the  outset,  that  I  am  discussing  the 
subject  only  from  the  standpoint  of  the  physician,  and  not 
that  of  the  moralist,  and  that  it  must  be  discussed  in  the 
light  of  present-day  knowledge  upon  the  subject  of  venereal 
disease.  Perhaps  it  may  be  possible,  at  some  future  time, 
to  render  people  immune  to  gonorrhea  and  syphilis,  just 
as  we  render  them  immune  to  smallpox,  or  to  abort  the 
disease  immediately  after  it  has  been  contracted,  and  before 
any  serious  results  have  ensued.  When  that  time  comes, 
the  entire  subject  will  take  on  an  entirely  different  aspect, 
and  will  perhaps  be  discussed  entirely  differently. 

The  answer  that  comes  most  readily  to  our  minds  is : 
Prevent  the  spread  of  venereal  disease,  or,  if  that  is  not 
feasible,  abort  it  or  cure  it  rapidly  and  permanently. 


256  Disorders  of  the  Sexual  Function. 

The  prevention  of  the  spread  of  venereal  diseases  in- 
volves the  whole  question  of  the  suppression  of  prostitution. 
This  is  a  very  complex  question  and  volumes  have  been 
written  upon  the  subject.  AMthout  going  into  the  causes 
of  the  failure,  it  is  an  absolute  fact  that  from  time  im- 
memorial, civilized  nations  have  struggled  with  this  problem, 
and  have  always  failed  to  suppress  it,  except  temporarily. 
Heavy  fines,  imprisonment,  and  even  the  death  penalty  have 
been  imposed  at  various  times,  but  without  success.  In 
New  York  City  attempts  have  often  been  made  to  eliminate 
houses  of  prostitution,  but,  thus  far,  all  these  efforts  have 
had  only  a  temporary  effect.  Prostitutes  were  driven  merely 
from  one  district  to  another,  and  no  permanent  suppression 
has  taken  place. 

As  a  further  means  of  preventing  the  spread  of  venereal 
disease,  we  have  the  immediate  treatment  of  the  patient 
right  after  exposure.  Undoubtedly  the  method  employed 
in  the  army  and  navy  has  had  excellent  results,  but  it  has 
its  limitations.  In  the  first  place,  the  strict  military  dis- 
cipline which  can  be  applied  to  soldiers  and  sailors  can 
never  be  applicable  to  the  general  public,  and,  in  the  second 
place,  this  prophylactic  method  does  not  remove  the  danger 
of  infection,  but  only  reduces  the  chances  of  infection.  In 
other  words,  if  a  thousand  sailors  expose  themselves  to 
infection,  a  larger  percentage  will  escape  infection  under 
the  army  and  navy  method  than  before.  Not  even  the 
most  enthusiastic  adherent  of  this  method  would  claim  that 
any  particular  individual  would  escape  infection  by  em- 
ploying the  prophylactic  army  and  navy  package.  What 
then  are  the  chances  of  infection  from  illicit  intercourse? 


Continence.  257 


It  goes  without  saying  that  if  a  person  has  connection 
with  a  prostitute  he  ought  not  to  be  surprised  if  she  infects 
him.  Even  those  houses  that  have  a  visiting  physij:ian 
are  not  safe,  especially  as  regards  gonorrhea,  for  the  fol- 
lowing reasons : — 

I.  It  is  easy  for  the  woman  to  douche  before  examina- 
tion and  so  deceive  the  physician. 

II.  The  woman  may  become  infected  between  the  doc- 
tor's visits,  or  show  the  first  signs  of  the  disease  between 
the  visits. 

III.  The  chronic  or  so-called  "cured"  cases  form  the 
most  important  source  of  contamination  in  this  group.  It 
is  perfectly  possible  that  a  woman  who  has  had  gonorrhea 
may  show  absolutely  no  pus  or  discharge  whatsoever  on 
her  genital  organs,  and  that  scrapings  from  them  may  show 
no  gonococci  either  when  directly  examined  or  even  on  cul- 
ture; and  yet  this  woman,  under  the  stimulus  of  sexual 
excitement,  may  pour  out  millions  of  gonococci  with  the 
mucus  from  the  glands  where  they  are  hidden  and  infect 
her  partner.  Those  who  have  paid  particular  and  careful 
attention  to  this  source  of  infection  will  agree  with  me  that 
practically  once  a  woman  has  had  gonorrhea  there  is  no 
way  of  telling  from  physical  examination  whether  she  is 
cured  or  not. 

Then  we  have  the  servant-girls,  the  chamber-maids,  and 
other  "sure  things."  To  anyone  who  has  had  a  large 
experience  in  venereal  diseases  it  is  a  standing  joke  to  see 
the  large  amount  of  disease  contracted  from  these  so-called 
"sure  things."  To  all  patients  of  mine  alleging  to  have 
such  a  "sure  thing"  I  have  but  one  answer,  and  that  is, 

17 


258  Disorders  of  the  Sexual  Function. 

"If  they  go  with  you  they  go  with  others,  and  so  you  are 
not  safe," 

Lastly,  we  have  married  women,  especially  the  so-called 
"respectable  married  women."  I  have  had  several  cases 
that  have  made  a  deep  impression  upon  me  in  this  respect. 
I  have  had  two  ladies  under  treatment  who  were  eminently 
and  absolutely  respectable  and  above  all  suspicion,  and  yet 
both  were  suffering  from  gonorrhea,  having  been  infected 
by  their  husbands,  who,  by  the  way,  were  also  under  my 
care.  Now,  here  is  the  point  I  wish  to  emphasize :  Surely, 
if  any  stranger  could  entice  either  of  these  ladies  to  have 
connection,  he  could  be  absolutely  certain  of  their  respect- 
ability and  also  as  absolutely  certain  of  contracting  gon- 
orrhea. If  one  has  connection  with  a  married  woman 
he  must  be  able  to  guarantee  for  her  husband,  which 
is,  indeed,  a  very  difficult  matter.  Moreover,  the  very  fact 
that  she  has  connection  with  him  proves  that  she  is  not 
respectable,  and  brings  her  in  line  with  the  arguments  ad- 
vanced against  the  other  "sure  things." 

As  a  practical  proof  of  all  these  arguments,  it  may  be 
advanced  that  the  rich,  who  surely  can  obtain  anything 
they  desire,  with  their  money,  suffer  just  as  much  from 
venereal  diseases  as  do  others.  Taking  it  all  and  all,  we 
may  practically  sum  up  the  whole  thing  by  the  formula: 
Illicit  connection  is  equal  to  venereal  disease. 

Even  the  use  of  the  condom  is  not  an  absolutely  safe 
protection,  for  I  have  seen  cases  where  the  condom  broke 
and  gonorrhea  was  contracted,  and  also  where  the  initial 
lesion  on  the  penis  occurred  high  up  near  the  root  and 
above  the  level  of  the  condom. 


Continence.  259 


Although  great  strides  have  been  made  in  the  treatment 
of  venereal  diseases  in  the  last  few  years,  their  abortion  or 
rapid  cure  has  not  yet  been  realized.  In  syphilis,  the  idea 
of  aborting  the  disease  with  salvarsan  has  proven  a  failure, 
and  in  spite  of  the  excellent  therapeutic  properties  of  this 
preparation,  we  cannot  cure  syphilis  any  more  rapidly  than 
before.  Surely,  no  conscientious  physician  would  permit  a 
syphilitic  to  marry  before  several  years  of  observation  have 
passed.  With  the  present  use  of  the  Wassermann  test, 
we  actually  keep  the  patient  under  observation  much  longer 
than  previously  in  many  cases.  In  gonorrhea,  the  abortive 
treatment  is  successful  only  in  a  very  small  percentage  of 
cases,  and  is  only  applicable  to  patients  who  present  them- 
selves within  twenty-four  to  thirty-six  hours  after  the 
beginning  of  the  discharge.  The  complement-fixation  test 
and  modern  improved  cultural  methods  in  diagnosis  have 
likewise  had  the  effect  of  keeping  the  patient  under  obser- 
vation much  longer  than  previously. 

We  see,  therefore,  that  in  spite  of  the  progress  in  med- 
icine the  prevention,  abortion,  or  rapid  cure  of  venereal 
diseases  has  not  been  realized,  and  has  not  helped  to  solve 
the  situation  under  consideration.  On  the  contrary,  advances 
in  medicine  have  but  emphasized  that  our  m.ost  careful 
methods  of  diagnosing  a  cure  so  far  have  been  inefficient. 

We  now  come  to  the  question  of  continence  as  a  pos- 
sible solution  of  the  difficulty.  This  question  must  be  dis- 
cussed with  perfect  freedom,  and  with  due  regard  to  all 
the  arguments  pro  and  con.  To  ridicule  it,  and  call  everyone 
a  fool  who  differs  from  one's  pet  opinion,  is  not  scientific 
argument. 


260  Disorders  of  the  Sexual  Function. 

Having  shown  that  it  is  practically  impossible  to  avoid 
venereal  disease  when  having  illicit  intercourse,  we  now 
come  to  the  questions :  Is  illicit  intercourse  necessary  ?  Is 
continence  physiological  and  in  harmony  with  perfect 
health?  Can  a  young,  unmarried  man  remain  continent 
and  still  be  healthy? 

Upon  the  answer  to  these  questions  hinge  a  large  por- 
tion of  the  causes  of  the  spread  of  venereal  disease,  for  it 
must  be  acknowledged  that  this  portion  of  medicine  bears 
exactly  the  same  relation  to  morality  and  religion  as  every 
other  portion  of  medicine.  In  every  religion  the  most 
stringent  laws  are  to  a  certain  extent  subservient  to  those 
of  health.  The  orthodox  Hebrew  may  eat  articles  of  food 
proscribed  by  the  dietary  laws  if  necessary  to  his  health. 
Even  the  rite  of  circumcision  and  the  abstinence  from  food 
on  the  Day  of  Atonement,  the  most  sacred  customs  to  the 
orthodox  Hebrew,  may  be  interfered  with  if  health  is  at 
stake.  The  religious  Catholic  and  Protestant  may  neglect 
abstaining  from  food  on  certain  fast  days  if  prejudicial  to 
his  health.  And  so  it  is  with  the  subject  under  consider- 
ation. Our  clergymen  may  preach  chastity  and  purity  from 
morning  till  night,  and  may  bring  to  their  aid  the  most 
potent  religious,  moral,  and  ethical  arguments ;  if  the  physi- 
cian, however,  says  that  it  is  detrimental  to  health  to 
be  continent,  that  coitus  is  absolutely  necessary  for  the 
healthy  adult,  our  patients  will  throw  aside  the  teachings 
of  the  clegjmian  and  listen  to  those  of  the  physician,  and 
(I  say  it  with  deep  religious  feeling)  will  be  perfectly 
right  in  so  doing.  No  matter  what  the  law  says,  no  one 
would  condemn  a  hungry  man  for  stealing  a  loaf  of  bread 


Continence.  261 


to  eat,  and  none  ought  to  condemn  a  healthy  adult  for 
having  connection  if  tliis  is  absolutely  essential  to  his 
existence.  And,  as  I  have  shown  that  practically  illicit 
connection  equals  venereal  disease,  if  we  physicians  con- 
sider illicit  connection  necessary,  we  ought  not  to  wonder 
at  the  prevalence  of  venereal  disease,  or  hope<  to  see  it 
decrease. 

In  the  following  pages  I  shall  endeavor  to  prove  that 
continence  is  not  detrimental  to  health,  considered  either 
from  a  physiological  or  psychological  standpoint. 

First,  considered  from  the  point  of  view  of  physiology. 
It  is  indeed  remarkable  that  several  years  ago,  when  I  con- 
sulted almost  every  work  on  physiology  published  in  the 
English  language  during  the  preceding  ten  years,  not  one 
had  anything  to  say  on  the  question.  This  search  included, 
besides  others,  textbooks  by  the  following  authors: 
Landois,'^2  Kirkes,^^  Brubaker,i«  Schafler,^!!  Raymond,!^'^ 
Ott,«8  Foster,37  Hall,^^  Stirling,i2i  johnson,^^  Hare^^  and 
"American  Textbook  of  Physiology."  In  1875,  Austin 
Flint,  Jr.,^^  makes  a  slight  reference  to  the  question,  when 
he  says  that  "sexual  intercourse  is  only  physiological  when 
confined  within  the  limits  of  legitimacy."  With  this  one 
slight  reference  as  an  exception,  I  could  at  that  time  find 
no  data  in  works  on  physiology. 

But  we  have  other  authorities  (outside  of  physiology)' 
who  have  expressed  opinions  on  this  question.  No  less  an 
authority  than  Prof.  Bryant,^  ^  the  great  English  surgeon, 
says :  "The  student  should  remember  that  the  functions  of 
the  testicle,  like  those  of  the  mammary  gland  and  uterus, 
may  be  suspended  for  a  long  period,  possibly  for  life,  and 


262  Disorders  of  the  Sexual  Function. 

yet  its  structure  may  be  sound  and  capable  of  being  roused 
into  activity  on  any  healthy  stimulation.  Unlike  other 
glands,  it  does  not  waste  or  atrophy  for  want  of  use." 

This  opinion  from  the  great  English  surgeon  answers 
a  very  important  objection  to  continence  which  I  have  seen 
urged  by  many  physicians.  I  have  heard  physicians  argue 
as  follows:  ''Every  organ  of  the  body,  if  not  in  use  for 
a  long  time,  atrophies;  muscles  lose  their  power,  joints  be- 
come stiff,  the  stomach  and  intestines  refuse  to  secrete  the 
proper  digestive  ferments,  if  these  are  artificially  supplied 
for  a  long  time;  even  the  higher  functions  of  the  brain 
become  'rusty'  if  not  made  use  of,  therefore  the  genital 
apparatus  ought  to  be  kept  active  or  else  it  will  atrophy 
and  become  useless," 

It  is,  however,  a  fact  that  the  sexual  organs  are  con- 
structed upon  entirely  different  principles  than  most  of  the 
other  organs  of  the  body.  They  are  constructed  for  inter- 
mittent action  and  their  functions  may  be  suspended  indef- 
intely  without  harm  to  either  their  anatomy  or  physiolog)^ 
Witness  the  mammary  gland.  A  woman  becomes  pregnant 
and  gives  birth  to  a  child,  and  immediately  the  gland,  which 
had  remained  dormant  for  years,  swells  up  and  secretes 
milk.  After  lactation  is  finished  the  gland  becomes  smaller 
and  inactive.  She  may  not  become  pregnant  again  for  ten 
or  more  years,  and  during  all  this  while  the  gland  is  not 
in  use,  but  even  after  this  long  period,  should  she  again 
become  pregnant,  it  will  again  swell  up  and  be  absolutely 
useful  in  spite  of  the  long  period  of  disuse.  The  same  is 
true  of  the  uterus.  I  have  gone  somewhat  in  detail  into 
this  question,  because  it  is  very  important,  and  is  constantly 


Continence.  263 


being  brought  up  by  the  opponents  of  the  continence  theory 
and  is  very  apt  to  impress  the  laity, 

James  Foster  Scott/ ^^  the  great  authority  on  sexual 
instinct,  says :  "If  the  penalties  meted  out  to  the  impure 
are  so  many,  there  is  yet  comfort  for  the  unmarried  man 
in  those  pages  which  show  that  perfect  continence  is  quite 
compatible  with  perfect  health,  and  thus  a  great  load  is  at 
once  lifted  from  the  mind  of  him  who  wishes  to  be  con- 
scientious as  well  as  virile  and  in  health  with  all  the  organs 
of  the  body  performing  their  proper  functions."  And 
again,  on  page  95  :  "There  is  an  erroneous  and  widely 
spread  belief  that  exercise  of  the  sexual  functions  is  neces- 
sary in  order  to  maintain  health.  .  .  .  The  reproduc- 
tive glands  have  been  so  constructed  that  their  specific 
activities  can  be  suspended  for  long  periods  of  time  without 
their  atrophy  or  the  slightest  impairment  of  function.  In 
this  particular  they  resemble  the  inherent  capabilities  of  a 
woman's  breasts,  which  can  remain  quiescent  for  years  and 
when  called  into  demand  physiologically  respond  with  per- 
fect function."  And  again,  on  page  99  :  "It  is  a  pernicious 
pseudo-physiology  which  teaches  that  the  exercise  of  the 
generative  functions  is  necessary  in  order  to  maintain  one's 
physical  and  mental  vigor  of  manhood." 

Acton^  says :  "One  argument  in  favor  of  incontinence 
deserves  special  notice,  as  it  purports  to  be  founded  on 
physiology.  I  have  been  consulted  by  persons  who  feared, 
or  professed  to  fear,  that  if  the  organs  were  not  regularly 
exercised  they  would  become  atrophied,  or  that  in  some 
way  impotence  might  be  the  result  of  chastity.  This  is  the 
assigned  reason  for  committing  fornication.     There  exists 


264:  Disorders  of  the  Sexual  Function. 

no  greater  error  than  this  or  one  more  opposed  to  physio- 
logical truth.  In  the  first  place,  I  may  state  that  I  have, 
after  many  years'  experience,  never  seen  a  single  instance 
of  atrophy  of  the  generative  organs  from  this  cause. 
No  continent  man  need  be  deterred  by  this 
apocryphal  fear  of  atrophy  of  the  testes  from  living  a  chaste 

life." 

Beale,^^  professor  at  King's  College,  London,  says: 
"And  I  would  remark  here  that,  notwithstanding  very 
strong  assertions  to  the  contrary,  and  by  authorities  who 
profess  to  have  thoroughly  studied  the  question,  no  suf- 
ficiently valid  objections  have  been  established  upon  reason- 
able grounds,  or  upon  facts  of  physiology  and  health,  to 
living,  nay,  to  passing  life  in  a  state  of  celibacy."  And 
again,  on  page  64,  in  the  chapter  called  "Question  of  Physio- 
logical Necessity,"  he  says:  "The  argument  that  if  mar- 
riage cannot  for  various  reasons  be  carried  out,  it  is 
nevertheless  necessary,  upon  physiological  grounds,  that  a 
substitute  of  some  kind  should  be  found,  is  altogether 
erroneous  and  without  foundation.  It  camiot  be  too  dis- 
tinctly stated  that  the  strictest  temperance  and  purity  is  as 
much  in  accordance  with  physiological  as  moral  lav,^,  and 
that  the  yielding  to  desire,  appetite,  and  passion  is  no  more 
to  be  justified  upon  physiological  or  physical  than  upon 
moral  or  religious  grounds." 

Sir  James  Paget,^^  the  eminent  English  surgeon,  says: 
"Many  of  your  patients  will  ask  you  about  sexual  inter- 
course, and  some  will  expect  you  to  prescribe  fornication. 
Chastity  does  no  harm  to  mind  or  body;  its 
discipline  is  excellent;  marriage  can  be  safely  waited  for." 


Continence.  265 


It  must,  however,  in  all  fairness  be  mentioned  that  there 
are  some  who  hold  directly  opposite  views  on  this  question, 
and  in  order  to  be  candid  I  shall  cite  some  of  these  views 
and  attempt  to  point  out  their  fallacies. 

Lydston"^  says :  "No  man  or  woman  at  adult  age  is 
in  perfect  physiological  condition  unless  the  sexual  function 
is  naturally  and  regularly  performed." 

This  would,  indeed,  be  a  remarkable  statement,  but  it 
loses  its  remarkability  as  we  turn  to  another  chapter  in 
the  same  work, — that  on  masturbation.  Herein  we  see,  as 
I  shall  presently  quote,  that  even  this  author,  who  holds 
such  extreme  views,  cannot  deny  that  continence  is  per- 
fectly in  accord  with  physiological  well  being.  He  says: 
"There  is  one  point  in  sexual  physiology  that  should  be 
impressed  upon  our  patients.  The  impression  prevails 
among  young  men  that  exercise  of  the  sexual  function  is 
an  absolute  physical  necessity,  irrespective  of  the  method 
of  its  accomplishment.  Indeed,  it  is  probable  that  some 
physicians  who  certainly  ought  to  know  better  foster  this 
idea  by  ill-weighed  and  injudicious  counsel.  This  idea  is 
most  pernicious  in  its  effects,  and  it  becomes  our  duty  to 
correct  it.  Although  no  adult  man  or  woman  under  exist- 
ing social  conditions  is  physiologically  well  balanced  in  a 
state  of  celibacy,  one  may  be  perfectly  healthy  and  physi- 
cally vigorous  while  leading  a  life  of  absolute  continence, 
if  the  mind  is  properly  disciplined  and  the  body  made 
completely  subservient  to  the  will.  The  excuse  of  physical 
necessity  is  too  often  a  subterfuge  to  justify  fornication 
and  even  masturbation.  That  such  an  excuse  should  ever 
be  offered  is   striking  testimony  regarding  the  prevalent 


266  Disorders  of  the  Sexual  Function. 

ignorance  of  sexual  physiology.  A  better  education  in  the 
ethics  and  physiological  aspects  of  the  sexual  function  is  a 
crying  necessity.  The  patient  should  be  impressed  with 
the  idea  that  its  (the  sexual  apparatus)  function  may  be 
held  in  abeyance  for  very  long  periods,  even  for  life,  with- 
out necessarily  producing  physical  injury.  When  thus  held 
in  abeyance  the  generative  function  may  be  called  into 
action  at  any  time  and  present  no  evidences  of  deteriora- 
tion from  the  compulsory  rest." 

The  writer  evidently  means  that  sexual  intercourse  in 
adult  life  is  desirable  for  the  maintenance  of  the  physiologi- 
cal balance,  but  is  not  a  necessity  under  ideal  conditions 
of  sexual  education;  but  he  w^ould  lead  us  to  infer  that 
under  the  artificial  conditions  that  constitute  society  today 
it  may,  and  often  does,  become  a  necessity. 

It  is,  of  course,  obvious  that  the  purer  one  is  brought 
up  and  the  purer  his  associates  are,  the  purer  his  thoughts 
will  be,  and  the  easier  it  will  be  for  him  to  remain  con- 
tinent. And,  on  the  other  hand,  if  the  mind  is  constantly 
kept  excited  by  the  reading  of  immoral  literature,  or  the 
presence  of  lewd  associates,  it  becomes  extremely  difficult 
to  refrain  from  sexual  intercourse.  This  difficulty  is 
enormously  increased  if  sexual  intercourse  has  already  been 
indulged  in,  so  that  what  was  at  first  a  novelty  finally 
becomes  a  habit.  At  this  stage  fornication  may  become  a 
necessity  in  the  same  sense  as  alcohol  to  the  habitual 
drunkard  or  morphine  to  the  morphine  fiend. 

In  carefully  looking  over  the  authorities  that  believe 
sexual  intercourse  a  necessity,  two  important  facts  are 
observed : — 


Continence.  267 


The  first  is  the  twosidedness  of  their  statements,  the 
hemming  and  ha\ving  about  the  matter,  showing  that  they 
themselves  are  not  quite  certain  about  it.  Thus  they  say 
that  sexual  intercourse  is  a  necessity,  and  at  the  same  time 
they  caution  us  against  telling  our  patients  this  fact.  It  is 
for  this  reason  that  at  the  commencement  of  this  discus- 
sion, I  have  stated  the  issue  fairly  and  squarely.  I  said 
there,  and  I  repeat  it  here,  that  if  sexual  intercourse  is  a 
necessity,  it  ought  not  only  to  be  allowed,  but  encouraged; 
also,  if  continence  is  prejudicial  to  health,  it  should  be  dis- 
couraged, no  matter  what  religion  or  morality  says. 

The  second  important  fact  that  strikes  one  is,  that  these 
authorities  consider  that  the  only  alternative  to  sexual  inter- 
course is  masturbation,  or,  in  other  words,  that  if  a  healthy 
adult  does  not  indulge  in  sexual  intercourse  he  is  bound 
to  masturbate.  This  is  a  very  grave  scientific  error.  While 
it  is  admitted  that  a  large  number  of  boys  and  young  men 
masturbate,  it  is  absolutely  denied  that  masturbation  is  in 
any  way  a  physical  necessity  or  alternative  to  sexual  inter- 
course. Masturbation  is  generally  acquired  at  puberty, 
following  the  awakening  of  the  sexual  sense,  but  it  is  also 
exceedingly  common  in  very  young  boys  and  even  infants, 
long  before  the  sexual  sense  is  developed.  As  a  matter  of 
rfact,  in  a  large  percentage  of  cases  the  habit  is  dropped 
before  sexual  intercourse  is  commenced.  I  have  also  found 
the  habit  continued  in  married  men  while  indulging  in 
regular  intercourse. 

While  admitting  that  masturbation  does  cause,  for  the 
time  being,  pronounced  nervous  symptoms  (see  chapter  on 
Masturbation)    such  as  dreaminess  instead  of  being  wide 


268  Disorders  of  the  Sexual  Function. 

awake,  also  readiness  to  submit  to  insult  rather  than  fight, 
etc.,  I  would  still  unhesitatingly  say,  after  a  large  experi- 
ence in  both  cases  of  masturbation  and  gonorrhea,  better 
ten  years  of  masturbation  than  one  year  of  gonorrhea. 
There  is  not  the  slightest  shadow  of  a  proof  that  mastur- 
bation ever  produced  insanity,  permanent  loss  of  memory, 
or  even  permanent  neurasthenia.  While,  as  before  stated, 
masturbation  may  produce  various  nervous  phenomena,  it 
has  been  my  experience  that  in  practically  every  case  these 
symptoms  were  only  temporary,  and  no  matter  how  long 
they  had  existed  or  how  long  masturbation  had  been  prac- 
tised, all  the  symptoms  promptly  disappeared  as  soon  as 
treatment  was  instituted  and  the  habit  dropped.  Again, 
when  we  consider  that  the  vast  majority  of  adults  have  at 
one  time  or  another  masturbated,  we  must  not  be  surprised 
that  also  among  the  insane  we  get  a  history  of  mastur- 
bation in  quite  a  good  many  cases.  As  I  have  shown, 
masturbation,  no  matter  of  what  intensity  or  duration,  can 
be  permanently  cured;  whereas  gonorrhea,  if  neglected,  is 
one  of  the  most  obstinate  of  diseases,  and  often  does  pro- 
duce permanent  incurable  pathological  conditions.  To  sum 
up,  then,  the  whole  matter,  I  would  say  that  masturbation 
is  not  at  all  a  physical  necessity  to  those  who  desire  to 
remain  continent;  but,  even  if  it  were,  it  is  not  nearly 
as  great  an  evil  as  gonorrhea  or  syphilis,  and  can  be  rapidly 
and  permanently  cured. 

I  will  quote  just  one  more  authority  who  holds  the 
extreme  view  that  sexual  intercourse  is  necessary  to  physio- 
logical well-being. 

Von  Schrenck-Notzing,^^^  page  30,  says:    "Likewise  in 


Continence.  269 


man  enforced  abstinence  may  endanger  the  freedom  of  the 
will  and  lead  to  perversity  of  the  sexual  act."  Again,  on 
page  39  he  says:  "The  best  cure  for  Onanism  and  other 
manifestations  of  sexual  hyperesthesia — with  few  excep- 
tions there  can  be  no  doubt  upon  that  point — ^lies  in  regular 
sexual  intercourse."  And,  on  page  40:  "Therefore,  the 
chaste  youth  should  exercise  sexual  abstinence  as  long  as 
he  is  able  to  restrain  the  instinct  without  injury  to  his 
health.  Should  he  be  in  danger  owing  to  increasing 
strength  of  his  sexual  impulse,  of  Onanism,  of  falling  a 
victim  to  satyriasis,  or  perverse  sexual  indulgence,  then  it 
becomes  the  duty  of  his  teacher  and  his  physician  to  cause 
indulgence  in  coitus  and,  too,  to  acquaint  the  neophyte  with 
precautionary  measures  which  will  guard  against  excesses, 
infection,  and  the  procreation  of  illegitimate  offspring." 

The  views  here  expressed  are  so  decided  that  they  can- 
not be  left  unnoticed,  and  it  behooves  us  to  examine  them 
closely. 

The  theory  that  abstinence  causes  satyriasis  or  other 
sexual  perversions  is  analogous  to  the  theory  that  sexual 
intercourse  is  a  physical  necessity.  After  most  carefully 
studying  this  very  important  question,  I  do  not  believe  that 
sexual  perversion  an}?-  more  than  insanity  is  caused  by 
abstinence,  but  rather  that  abstinence  may  be  but  one  of 
the  many  S3^mptoms  of  sexual  perversions.  The  fact  that 
a  sexual  pervert  who  satisfies  his  sexual  cravings  through 
various  disgusting  means  is  abstinent  from  regular  sexual 
intercourse  does  not  say  that  because  he  is  abstinent,  there- 
fore, he  is  led  into  sexual  perversity.  His  mind  is  so  consti- 
tuted that  he  simply  prefers  this  method  to  the  other.    If  one 


270  Disorders  of  the  Sexual  Function. 

follows  up  the  history  of  these  sexual  perverts,  he  would 
be  struck  by  the  fact  that  in  not  a  few  instances  these 
pervert  tendencies  started  quite  early  in  life,  even  before 
puberty,  when  surely  abstinence  could  not  have  been  the 
cause  of  them.  I  have  gone  somewhat  into  this  question 
in  the  chapters  on  Satyriasis  and  Nymphomania,  but  further 
discussion  into  this  very  interesting  subject  of  sexual  per- 
versions would  lead  me  far  beyond  the  limits  of  this  chapter. 

The  next  proposition  is  even  more  startling :  "The  best 
cure  for  Onanism  and  other  manifestations  of  sexual  hyper- 
esthesia— with  few  exceptions — lies  in  regular  sexual  inter- 
course." It  is  a  pity  that  the  author  does  not  give  us  the 
"few  exceptions,"  for  then  it  might  be  seen  that  they  em- 
brace practically  the  entire  subject.  As  is  well  known, 
Onanism  generally  starts  around  puberty,  or  even  before 
it,  and  continues  for  a  few  years  thereafter.  Does  this 
authority  mean  to  recommend  sexual  intercourse  at  the  ages 
of  12,  13,  14  or  15,  in  order  to  cure  the  habit?  If  not, 
then  one  of  his  "few  exceptions"  cuts  off  certainly  over  80 
per  cent,  of  the  cases,  for  the  largest  portion  of  them  start 
and  continue  during  these  ages. 

But  let  us  say  that  the  author  refers  only  to  adults. 
Even  if  there  were  no  other  remedy  for  sexual  hyperesthesia 
than  sexual  intercourse,  I  would  very  much  hesitate  to 
prescribe  a  remedy  which  carries  with  it  the  almost  certain 
risk  of  gonorrhea  or  syphilis.  Surely  the  "cure"  is  much 
worse  than  the  disease.  But,  happily  for  mankind,  there 
is  another  safe  and  certain  remedy.  In  the  chapter  on 
Masturbation  I  have  shown  that  the  hyperesthesia  in  the 
prostatic  urethra,  as  well  as  the  congestion  of  the  prostate 


Continence.  271 


gland  itself,  which  is  the  result  of  long-continued  mastur- 
bation, acts  reflexly  upon  the  sexual  centers  in  the  brain  and 
causes  the  intense  desire  to  masturbate.  Also,  that  as  soon 
as  the  local  condition  is  cured  by  prostatic  massage  and 
deep  urethral  silver-nitrate  instillations  (see  chapter  on 
Masturbation),  the  desire  for  masturbation  ceases,  and  the 
patient  is  cured  of  the  habit. 

Let  us  now  consider  the  last  proposition,  which,  to  state 
briefly,  in  order  to  avoid  repetition,  is  that  the  chaste 
youth  should  refrain  from  sexual  intercourse  as  long  as  he 
can,  but,  as  soon  as  such  abstinence  seems  to  interfere  with 
his  health,  his  physician  is  to  advise  sexual  connection,  tell- 
ing him  how  to  avoid  venereal  disease  and  illegitimate 
offspring. 

The  first  part  of  this  paragraph  peculiarly  illustrates  the 
hemming  and  hawing  about"  the  subject  which  I  have  pre- 
viously alluded  to.  It  is  simply  a  most  cowardly  device 
on  the  part  of  the  physician  for  throwing  off  his  own  re- 
sponsibility, and  putting  it  upon  the  patient.  It  may  be 
good  politics,  but  it  is  neither  scientific  nor  in  accord  with 
the  ethical  obligation  that  the  physician  owes  to  his  patient. 
To  tell  a  young  man  "Don't  have  connection,  but  when 
you  can  no  longer  refrain  from  it,  have  it,"  is  simply  to 
give  a  silent  consent  to  it;  for  every  young  man  will 
quickly  come  back  and  say  that  he  cannot  refrain  from  it. 
If  he  later  presents  himself  with  a  venereal  disease,  the 
doctor  will  say:  'T  told  you  so;  I  told  you  not  to  have 
connection,  but  you  would  not  listen  to  me." 

But  the  advice  (according  to  the  author)  does  not  end 
here.     The  physician  is  to  instruct  the  youth  how  to  avoid 


272  Disorders  of  the  Sexual  Function. 

venereal  disease  and  illegitimate  offspring.  The  author 
very  wisely  omits  to  tell  us  what  these  instructions  consist 
in.  A  statement  like  this  may  possibly  be  swallowed  by 
the  general  public,  but  to  the  physician,  especially  one  with 
experience  in  genitourinary  work,  it  is  the  rankest  hypoc- 
risy. If  the  physician,  with  the  proper  light  and  instru- 
ments, the  woman  in  the  proper  position,  with  the  aid  of 
the  speculum,  the  microscope  and  the  culture  plate,  cannot 
always,  or  even  generally,  be  positive  that  his  patient  is  free 
from  infection,  how  in  the  name  of  all  the  gods  at  once 
can  the  young  man,  without  this  knowledge  and  facilities, 
tell  whether  the  woman  is  safe  or  not?  It  cannot  be  too 
firmly  impressed  upon  the  public  that  a  man  does  not  gen- 
erally become  infected  by  a  woman  with  an  acute  gonor- 
rhea; it  is  mostly  from  women  with  chronic  gonorrhea, 
with  little  or  no  visible  pus,  that  most  gonorrheas  are  con- 
tracted. It  is  just  at  this  stage  that  the  physician  needs 
all  modern  resources  to  determine  whether  the  .  case  is 
infectious  or  not,  and  it  is  ridiculous  to  expect  the  lay 
young  man  to  make  the  diagnosis.  The  second  part  of  the 
proposition,  i.e.,  the  prevention  of  illegitimate  offspring, 
leads  us  into  the  realms  of  criminality,  and  such  a  state- 
ment ought  not  to  be  tolerated  in  any  legitimate  monograph. 

I  have  entered  into  some  detail  in  the  discussion  of 
this  theory  of  von  Schrenck-Notzing,  because  it  is  a  typical 
illustration  of  the  arguments  advanced  by  those  who  hold 
this  theory. 

In  this  connection  I  may  quote  Sturgis^^^  as  follows: 
"Trainers  of  pugilists  and  of  men  who  are  entering  for 
athletic  contests  are  well  aware  of  the  effect  sexual  inter- 


Continence.  273 


course  exerts  upon  the  physical  and  mental  condition  of 
every  man,  and  coitus  is  the  one  thing  which  is  rigidly 
excluded,  and  about  which  the  strictest  laws  are  held.  An 
ex-pugilist  has  told  me  that  when  he  was  training  for  a 
fight,  at  the  beginning,  he  suffered  a  great  deal  from  want 
of  intercourse,  his  seminal  losses  were  frequent,  and  he 
had  large  and  repeated  pollutions,  but  in  a  short  time,  as 
soon  as  he  got  thoroughly  into  his  work,  these  entirely  dis- 
appeared and  indeed  he  thought  no  more  about  them,  but 
as  soon  as  his  work  was  finished  and  the  fight  was  over 
he  found  that  sexually  he  was  as  good  as  ever,  the  libido 
was  pronounced,  and,  as  he  expressed  it  to  me,  he  'could 
not  get  enough,'  and  I  am  satisfied,  not  only  from  this 
man's  experience  but  of  others  with  whom  I  have  talked, 
that  in  such  cases  there  is  no  loss  of  power  from  sexual 
abstinence,  provided  always  the  patient  is  not  keeping  his 
genital  organs  continually  irritated  by  dallying  with  women, 
by  reading,  talking,  or  thinking  about  matters  connected 
with  sexual  intercourse." 

I  have  thus  far  discussed  the  question  from  the  point 
of  view  of  the  anatomist  and  physiologist.  I  will  now 
briefly  discuss  it  from  the  neurologist's  viewpoint.  In  so 
doing  I  cannot  do  better  than  quote  from  one  of  the  great- 
est neurologists  in  history.  In  the  Lettsomian  Lectures  on 
Syphilis  and  the  Nervous  System,  Professor  Gowers^^  says : 
"With  all  the  force  that  any  knowledge  I  possess  can  give, 
and  with  any  authority  I  may  have,  I  assert,  as  the  result 
of  long  observation  and  consideration  of  facts  of  every 
kind,  that  no  man  ever  yet  was  in  the  slightest  degree  or 
way  the  better  for  incontinence;  and  I  am  sure,  further, 

18 


2Y4  Disorders  of  the  Sexual  Function. 

that  no  man  was  ever  yet  anything  but  better  for  perfect 
continence.  My  warning  is:  Let  us  beware  lest  we  give 
even  a  silent  sanction  to  that  against  which  I  am  sure  we 
should  resolutely  set  our  face  and  raise  our  voice."  Surely 
such  an  assurance  from  the  great  neurologist  ought  for- 
ever to  allay  the  fears  of  those  who  fear  wreck  of  the 
nervous  system,  submersion  of  the  freedom  of  will,  insanity, 
sexual  neuroses,  and  degenerations  as  the  result  of 
continence. 

The  lectures  from  which  the  above  quotation  was  taken 
were  delivered  by  Gowers  in  1889.  In  order  to  determine 
if  modern  neurological  research  work  might  possibly  alter 
this  opinion,  I  sent  a  circular  letter  in  19 10  to  many  of 
the  most  prominent  neurologists  in  the  United  States,  ask- 
ing them  if  they  had  ever  seen  cases  of  nervous  disease 
which  could  be  attributed  to  continence.  In  practically 
every  case  I  received  the  answer,  that  not  only  did  they 
consider  continence  physiological,  but  that  they  did  not  be- 
lieve, from  their  experience,  that  continence  ever  leads  to 
nervous  disease. 

It  has  been  claimed  that  continence  leads  to  impotence. 
This  accusation  must  therefore  be  faced  fairly  and  squarely. 

In  the  discussion  of  the  various  types  of  impotence  I 
have  pointed  out  that  there  is  one  form  which  occurs  in 
men  in  whom  the  sexual  functions  appear  very  late,  and 
last  but  a  short  time.  These  men  rarely  masturbate,  rarely 
have  pollutions,  have  very  slight  libido  and  easily  remain 
continent.  They  sometimes  marry  for  economic  or  other 
reasons,  and  are  impotent,  but  do  not  worry  much  about 
their  condition.     In  other  words,  in  these  cases  there  is  a 


Continence.  275 


congenital  lack  of  sexual  desire  and  power,  which  is  the 
cause  of  the  easy  continence  and  impotence. 

Cases  like  these  are  often  the  ones  brought  forward  as 
examples  of  impotence  having  been  caused  by  continence. 
The  careless  observer,  going  into  the  history  only  super- 
ficially, simply  takes  it  for  granted  that  the  man  is  impotent 
because  he  has  been  continent. 

I  have  also  called  attention  to  another  form  of  impo- 
tence in  which  the  etiology  and  pathology  are  just  the  reverse 
to  that  above  mentioned.  To  this  class  belong  men,  with 
normal  or  even  powerful  desire  and  passion,  who  indulge 
in  illicit  intercourse  for  years  before  marriage,  and  are  per- 
fectly potent.  They  then  become  engaged  to  be  married, 
and,  for  fear  of  infection,  remain  continent  during  the 
period  of  their  engagement.  Their  continence  however, 
consists  merely  in  abstinence  from  coitus.  They  see  their 
girl  every  night  for  months  or  even  for  a  year,  and  spoon 
for  hours  at  a  time.  As  a  result  of  this  continuous  spoon- 
ing, they  get  their  sexual  organs  and  sexual  centers  into  a 
hyperirritable  condition  but  stop  just  short  of  coitus.  In 
consequence  of  this,  their  sexual  organs  and  centers  become 
congested  and  hyperirritable,  until  they  finally  become  ex- 
hausted. (See  Pathology  of  Impotence,  p.  75.)  If  they 
marry  while  in  this  condition,  they  are  apt  to  suffer  from 
temporary  impotence. 

Here,  again,  the  careless  observer  might  conclude  that 
as  long  as  the  patient  indulged  in  coitus  he  was  potent,  but 
as  soon  as  he  remained  continent  for  a  long  time  he  be- 
came impotent,  and  that,  therefore,  the  impotence  was  the 
result  of  continence.     As  a  matter  of  fact,  however,  these 


276  Disorders  of  the  Sexual  Function. 

men  were  not  continent  in  the  scientific  sense  of  the  term, 
but  quite  the  opposite.  The  best  proof  of  this  is  the  ther- 
apeutic proof.  If  you  permit  such  a  man  to  continue  his 
attempts  at  coitus  he  will  continue  to  get  worse,  but  if  you 
insist  upon  true  scientific  continence  his  sexual  organs  will 
recuperate  rapidly  as  a  result  of  the  rest,  and  he  will  soon 
be  restored  to  the  normal. 

It  has  been  argued  that,  after  the  sexual  organs  are 
mature,  continence  is  contrary  to  nature,  that  the  object 
of  sexual  desire  and  coitus  is  not  merely  for  purposes  of 
procreation,  for  if  that  were  the  case  it  would  be  necessary 
to  indulge  perhaps  only  a  dozen  or  twenty  times  in  a  life- 
time. It  is  contended  that,  if  procreation  were  the  sole 
object  of  coitus,  it  follows  that  as  soon  as  the  wife  becomes 
pregnant  it  would  not  be  necessary  to  indulge  for  the  entire 
period  of  pregnancy  and  even  for  one  or  two  years  after 
the  birth  of  the  child.  Placing  the  maximum  child-bearing 
period  of  a  woman  as  perhaps  thirty  years,  it  can  easily 
be  figured  out  how  few  acts  of  coitus  are  required  if  its 
object  were  procreation  only. 

This  is  certainly  a  powerful  argument  against  conti- 
nence, and  seems  to  hold  up  the  whole  theory  of  continence 
to  ridicule.  It  must  be  fairly  met,  and,  after  devoting 
considerable  attention  to  it,  I  have  come  to  the  following 
conclusion : — 

It  is  undoubtedly  true  that  the  act  of  coitus  is  not  for 
purposes  of  procreation  only,  any  more  than  the  act  of 
eating  is  merely  for  the  purpose  of  sustaining  life.  Chit- 
tenden and  other  physiologists  have  shown  that  we  eat  far 
in  excess  of  what  we  actually  need  to  sustain  life.     If  the 


Continence.  277 


object  of  eating  were  only  to  supply  our  bodies  with  the 
necessary  elements,  a  few  ^simple  articles  of  diet  would 
suffice.  Most  of  us  eat  because  we  enjoy  the  things  we 
eat,  and  likewise  most  people  indulge  in  coitus  because 
they  enjoy  it.  But  here  comes  the  very  important  point: 
While  most  of  us  eat  because  we  enjoy  the  things  we  eat, 
we  would  not  voluntarily  eat  an}thing  which  would  seri- 
ously harm  us.  In  our  ignorance  we  might  perhaps  eat 
things  which  do  not  agree  with  our  digestive  apparatus, 
but  no  sensible  person  would  voluntarily  do  so.  /  douht 
whether  any  sane  person  would  partake  of  a  dish,  no  mat- 
ter how  tempting  it  appeared,  if  he  knew  there  was  danger 
of  contracting  syphilis  or  gonorrhea  thereby.  Of  course 
there  are  persons  with  such  weak  resisting  powers  who 
cannot  resist  a  tempting  dish  which  previous  experience 
has  shown  does  not  agree  with  them,  but  such  persons  are 
certainly  in  the  minority,  and  even  such  persons  would 
resist  if  the  risk  were  in  any  way  as  serious  as  contract- 
ing gonorrhea  or  syphilis. 

I  fully  realize  that  the  impulse  for  sexual  connection  is 
a  much  more  powerful  one  than  the  impiilse  to  partake  of 
a  tempting  dish,  but  the  difference  is  one  of  degree  only. 

It  is  the  same  with  the  act  of  coitus.  I  admit  that  in 
the  vast  majority  of  cases  it  is  indulged  in  for  the  pleas- 
ure it  affords,  and  it  is  perfectly  proper  for  married  people 
to  indulge  in  it  as  often  as  is  consistent  with  their  sexual 
powers,  irrespective  of  procreation.  Were  there  no  danger 
in  illicit  coitus,  the  question  would  be  solely  a  moral  one, 
and  medicine  would  have  nothing  to  do  with  it.  But  as 
past  experience  has  shown  the  very  grave  dangers  of  illicit 


278  Disorders  of  the  Sexual  Function. 

coitus,  the  above  argument  against  continence  at  once  falls 
to  the  ground. 

Lastly  we  come  to  the  argument,  that  continence  is  con- 
trary to  nature.  In  discussing  the  etiology  of  satyriasis  I 
have  touched  upon  this  very  subject,  and  will  again  repeat 
in  part  what  I  said  in  that  connection. 

In  the  earliest  stages  of  development,  nakedness  was  the 
rule,  and  cohabitation  was  practised  entirely  unrestrained 
by  law  or  morals,  simply  as  an  expression  of  unbridled 
passion.  No  restraint  was  imposed  upon  the  sexual  im- 
pulse, and  it  was  gratified  without  shame  or  formality. 
According  to  Herodotus^^^  many  of  the  natives  of  antiquity 
did  not  keep  the  sexual  relations  private,  but  cohabited  like 
animals  in  any  assemblage. 

This  condition  of  affairs  still  exists  today  among  uncivil- 
ized peoples.  Cook,^^  in  connection  with  his  first  voyage, 
mentions  that  at  Tahiti  he  saw  a  native  in  sexual  inter- 
course with  an  eleven-year-old  girl,  in  the  presence  of  the 
queen,  who  gave  him  directions  in  that  regard. 

As  a  result  of  centuries  of  education,  however,  civilized 
man  has  set  up  a  moral  code  for  himself,  which  dictates 
that  he  satisfy  his  sexual  needs  within  certain  limits  of 
modesty  and  morality,  and  not  like  the  brute,  whenever  the 
desire  seizes  him. 

In  discussing  the  atavistic  theory  of  satyriasis,  I  men- 
tioned that  were  a  normal  primitive  man  brought  into  con- 
tact v/ith  modern  society,  it  would  be  impossible  for  him 
to  control  his  sexual  appetite  as  does  the  civilized  man  of 
today,  after  centuries  of  education.  It  is  more  than  likely 
that  the  former  would  have  connection  at  every  opportunity. 


Continence.  279 


whenever  the  desire  seized  him,  and  to  all  intents  and 
purposes  he  would  be  practically  like  a  patient  afflicted  with 
satyriasis.  In  other  words,  if  a  man  were  born  today  with 
primitive  sexual  instincts,  and  with  that  lack  of  self-control 
which  is  normal  to  primitive  man,  we  would  certainly  con- 
sider him  as  suffering  from  satyriasis. 

This,  in  brief,  is  the  answer  to  the  argument  that  con- 
tinence is  contrary  to  nature :  Tell  a  dog  on  the  street 
that  he  must  not  have  connection  on  the  public  highway, 
but  must  restrain  his  desire  till  he  and  his  bitch  can  find 
a  dark  and  secluded  spot,  he  would  probably  resent  this 
interference  as  contrary  to  his  natural  instinct.  Nature 
teaches  us  to  satisfy  our  sexual  impulse  whenever  desire 
occurs,  and  this  would  really  be  the  most  physiological  way 
of  doing  things,  but  civilization  dictates  that  we  restrain 
our  passion  within  certain  bounds  of  decency  and  morality. 
It  is  just  as  much  against  nature  to  restrain  our  passion 
within  these  bounds  as  it  is  to  practise  continence  and  to 
restrain  it  within  bounds  of  ligitimacy,  especially  as  such 
restraint  in  normal  individuals  is  perfectly  physiological. 

In  connection  with  the  nature  argument  against  con- 
tinence, it  has  been  said  that  human  nature  has  ahvays  been 
the  same,  and  that  you  cannot  change  it,  and  that  there 
has  always  been  illicit  coitus  and  will  always  be,  as  long 
as  human  passions  and  desires  remain  the  same. 

I  have  just  shown,  by  comparing  primitive  man  with 
civilized  man,  that  you  can  change  human  nature,  in  spite 
of  the  fact  that  the  sexual  passion  is  probably  just  as  strong 
in  the  civilized  man  of  today  as  it  was  in  his  primitive 
ancestor. 


280  Disorders  of  the  Sexual  Function. 

But  we  need  not  go  back  to  primitive  man  for  com- 
parison. For  reasons  too  complicated  to  mention,  woman 
has  always  excelled  man  in  sexual  morality.  She  has 
always  been  more  moral  and  modest  than  man. 

And  yet  we  need  only  consider  her  as  portrayed  in  old 
English  literature,  as,  for  example,  in  the  original  edition 
of  the  Knights  of  the  Round  Table,  or  even  in  compara- 
tively modern  literature,  as  illustrated  in  Shakespeare's 
works,  to  appreciate  the  vast  difference  in  the  morality  of 
the  woman  of  several  centuries  ago  and  that  of  the  woman 
of  today. 

Heaven  knows  that  there  are  enough  immoral  women 
today,  and  that  there  are  many  single  as  well  as  married 
women  who  transgress  the  law  of  morality,  but  the  great- 
est pessimist  must  concede,  nevertheless,  that  these  women 
are  greatly  in  the  minority  in  proportion  to  the  feminine 
population.  In  fact  it  may  be  stated,  without  fear  of  con- 
tradiction, that  the  vast  majority  of  wives  and  daughters 
are  absolutely  moral.  Women  today  are  considered  virtu- 
ous as  a  matter  of  course,  until  the  contrary  has  been 
proven,  and  it  would  be  considered  a  gross  insult,  in  intro- 
ducing a  woman,  to  state  at  the  same  time  that  she  is 
virtuous.     There  is  no  necessity  for  such  a  remark. 

But  consult  literature  as  I  have  done,  and  see  what  was 
the  standing  of  woman,  and  the  opinion  concerning  her 
during  the  period  above  referred  to.  In  introducing  a 
woman,  or  in  recommending  her  in  marriage,  it  was  gen- 
erally deemed  necessary  to  descant  upon  her  sexual  virtue. 
It  was  not  taken  for  granted  that  a  woman  was  virtuous 
as  a  matter  of  course,  but,  if  she  were,  special  mention  was 


Continence.  281 


made  of  the  fact,  while  men  were  never  expected  to  be 
virtuous  in  those  days.  In  other  words,  the  woman  of  that 
period  occupied  the  same  position  in  sexual  morality  as 
does  the  man  of  today. 

The  world  has  been  advancing;  the  woman  of  today  is, 
in  the  vast  majority  of  cases,  a  moral  woman.  Man  has 
been  advancing  also,  and  will,  I  believe,  continue  to  ad- 
vance until  he  will  some  day,  not  very  far  distant,  be  far 
more  virtuous  than  ever  before.  Woman  demands  it  of 
him  today,  whereas  less  than  ten  years  ago  she  did  not 
expect  him  to  have  been  virtuous  before  marriage.  What 
woman  demands  of  man,  she  is  bound  to  obtain. 


CHAPTER  XVIII. 

SOME  UNUSUAL  FOEMS  OF  SEXUAL  NEUROSES. 

General   considerations.     Illustrative   cases.     Results   of   treatment 
not  due  to  psychic  effects. 

In  the  following  pages  I  will  not  consider  the  more 
common  forms  of  sexual  neurasthenia,  such  as  impotence, 
masturbation,  pollutions,  etc.  In  all  these,  from  the  very- 
nature  of  the  condition,  the  attention  of  the  physician  is  at 
once  directed  to  the  sexual  apparatus,  and  the  patient  is 
treated  either  by  his  regular  attendant  or  is  referred  by 
him  to  a  specialist. 

In  this  chapter,  however,  I  desire  to  discuss  some  of 
the  unusual  forms  of  sexual  conditions,  cases  in  which  the 
patients  present  symptoms  of  widely  different  varieties,  and, 
in  many  cases,  not  at  all  suggestive  of  the  sexual  apparatus. 
In  reading  the  cases  as  reported  herein,  together  with  their 
diagnoses  presented  at  the  very  beginning,  it  may  appear 
not  to  have  been  very  difficult  to  have  made  the  diagnosis 
or  to  have  seen  the  relationship  of  the  patients'  symptoms 
to  the  sexual  apparatus,  but  in  actual  practice  it  is  at  times 
far  from  easy  to  recognize  that  relationship.  In  the  first 
place,  we  must  remember  that  the  patients  do  not  come  to 
us  saying  that  they  are  suffering  from  sexual  neurasthenia 
and  have  such  and  such  symptoms  or  conditions.  Far  from 
it.  As  before  stated,  they  come  complaining  of  the  most 
diverse  symptoms,  making  no  mention  whatever  of  their 
sexual  condition ;  in  fact,  in  many  cases  not  even  suspecting 
that  their  condition  or  train  of  nervous  symptoms  bears  any 
(282) 


Unusual  Sexual  Neuroses.  283 

relationship  to  the  sexual  organs.  It  often  takes  consider- 
able questioning  to  bring  out  the  sexual  etiology,  and  very 
often  the  most  painstaking  examinations  and  interrogations 
are  necessary  before  we  can  determine  that  the  patients' 
symptoms  are  due  to  reflexes  from  the  sexual  apparatus. 
In  many  cases  the  genitourinary  specialist  must  call  to  his 
aid  the  neurologist  for  differential  diagnosis,  before  ascrib- 
ing the  blame  to  the  sexual  organs.  Similarly,  however, 
the  neurologist  should  call  to  his  aid  the  genitourinary 
specialist  for  a  complete  examination  of  the  sexual  organs 
in  cases  which  fail  to  respond  to  treatment  and  where  the 
etiology  is  doubtful. 

I  might  here  state,  in  passing,  that  the  average  physi- 
cian has  not  yet  awakened  to  the  importance  of  the  male 
sexual  organs  as  a  source  of  reflex  nervous  symptoms,  as 
compared  to  the  female  sexual  apparatus.  In  the  latter 
class  of  patients  the  pendulum  seems  to  have  swung  too 
far.  The  physician  has  long  since  learned  the  important 
influence  that  the  female  sexual  organs  exert  on  every 
organ  of  her  body.  No  physician  would  neglect  thorough 
gynecological  examination  where  the  etiology  of  any  ner- 
vous condition  is  not  clear.  I  have  said  that  there  has 
been  too  much  zeal  in  this  direction,  and  many  women  are 
subjected  to  treatment  and  operation  because  of  some 
slight,  supposedly  pathological  condition  found,  which  is 
thought  by  the  examiner  to  be  the  source  of  all  her  woes. 

For  a  study  of  sexual  neuroses  we  must  not  look  to  the 
genitourinary  clinics.  To  make  a  study  of  these  cases  I 
associated  myself  with  the  neurological  class  of  Dr. 
Abrahamson,  at  the  Mount  Sinai  Dispensary,  where  all  such 


284  Disorders  of  the  Sexual  Function. 

cases  were  referred  to  me.  A  special  room  was  set  aside 
adjoining  one  of  the  neurological  rooms,  where  I  made  a 
complete  genitourinary  examination  of  all  cases  sent  me. 
Besides  taking  a  complete  history  of  each  case,  palpating 
the  external  genitals,  and  the  prostate  and  seminal  vesicles 
per  rectum,  I  examined  the  anterior  urethra  with  the  ordi- 
nary endoscope,  and  the  posterior  urethra  with  the  \A'os- 
sidlo-Goldschmidt  posterior  urethroscope.  The  patients  did 
not  come  to  the  dispensary  complaining  of  sexual  trouble. 
They  came  complaining  of  various  neurological  symptoms, 
and  if  Dr.  Abrahamson,  after  going  into  the  history,  sus- 
pected or  determined  that  there  was  a  genital  source  for 
their  trouble,  he  referred  them  to  me  for  genitourinary  ex- 
amination and,  when  suitable,  for  treatment.  It  was  in  this 
way,  and  not  through  the  genitourinary  clinics  with  which  I 
have  been  and  am  still  connected,  that  I  have  been  able  to 
make  a  special  study  of  these  cases  as  well  as  those  of  impo- 
tence, masturbation,  and  kindred  ailments.  I  believe  this 
plan  of  having  a  genitourinary  examination-room  in  connec- 
tion with  a  neurological  department  is  a  most  excellent  one 
— a  far  better  practice,  to  my  mind,  than  the  one  so  often 
seen  in  other  neurological  clinics,  where  these  patients  are 
often  dismissed  with  a  dose  of  bromides  or  a  tonic,  with- 
out even  a  pretence  of  a  genitourinary  examination. 

Sexual  Neurasthenia  with  Unusual  Sexual  Sjonptoms. — ■ 
Patient  has  been  married  ten  years.  He  has  had  three  or 
four  attacks  of  gonorrhea,  the  last  attack  having  been  fifteen 
years  ago.  Has  had  also  a  left  epididymitis.  He  is  sterile 
and  his  semen  shows  no  spermatozoa.  Urination  is  normal 
by  day  and  absent  by  night.     His  chief  complaint  is  that  at 


Unusual  Sexual  Neuroses.  285 

night,  and  only  at  rare  intervals,  he  is  seized  with  a  severe 
pain  in  his  penis,  located  about  three-quarters  of  an  inch 
from  the  meatus.  This  pain  lasts  about  an  hour,  during 
which  time  the  entire  penis  shrinks  up  (does  not  bend) 
and  his  testicles  also  become  heavier  and  smaller.  If  an 
erection  comes  at  this  time,  the  pain  subsides.  This  the 
patient  ascribes  to  the  stretching  of  the  penis.  An  exami- 
nation shows  signs  of  an  old  left  epididymitis,  and  also  a 
thickened  right  epididymis.  This  condition  is  sufficient  to 
account  for  the  sterility.  The  prostate  is  enlarged.  The 
urine  is  turbid  and  full  of  long  shreds.  With  the  bougie 
a  houle,  a  distinct  stricture  is  found  in  the  anterior  urethra 
at  the  site  of  the  pain,  and  with  the  endoscope  we  also  see 
a  distinct  stricture  (hard  infiltration)  at  that  point. 

With  the  above  urethral  findings,  one  would  at  once 
naturally  conclude  that  the  stricture  was  the  cause  of  his 
symptoms.  This,  indeed,  was  my  impression.  I  therefore 
treated  the  patient  with  dilatation  of  the  stricture,  together 
with  massage  of  the  prostate  at  intervals  in  order  to  reduce 
its  congestion.  It  must  be  remembered  that,  previous  to 
the  patient's  coming  to  me,  he  had  the  attacks  only  at  rare 
intervals.  As  the  dilatation  of  his  urethra  progressed,  I 
noticed  that  although  the  local  condition  had  so  far  im- 
proved that  he  could  take  a  large-size  sound  (30  F.),  there 
was  absolutely  no  change  in  his  symptoms.  In  other  words, 
these  continued  to  recur  at  the  same  rare  intervals.  I  was, 
however,  struck  with  the  fact  that  whenever  the  prostatic 
urethra  was  irritated,  either  by  the  urethral  sound  or  by 
prostatic  massage,  a  typical  attack  was  evoked  that  same 
night.     In  other  words,  it  was  noticed  that  as  long  as  the 


286  Disorders  of  the  Sexual  Function. 

condition  of  the  anterior  urethra  was  treated  by  staffs  which 
only  touched  the  anterior  urethra,  no  effect,  either  good  or 
bad,  was  experienced  by  the  patient,  but  as  soon  as  these 
staffs  were  replaced  by  sounds  which  passed  into  the  blad- 
der, the  symptoms  at  once  became  aggravated.  I  further 
noticed  that  although  the  stricture  was  situated  in  the 
anterior  urethra,  no  bleeding  occurred  if  only  the  anterior 
staffs  were  used,  whereas  a  sound  passed  ever  so  gently 
into  the  bladder  would  almost  always  be  followed  by  some 
bleeding.  I  then  concluded  that  in  spite  of  the  presence  of 
a  stricture  in  the  anterior  urethra  and  the  location  by  the 
patient  of  his  pain  almost  precisely  at  the  site  of  the  stric- 
ture, this  was  only  a  concomitant  condition,  and  not  at  all 
the  cause  of  his  symptoms.  As  soon,  therefore,  as  his 
anterior  urethra  was  sufficiently  dilated,  I  examined  the 
posterior  urethra  with  the  Wossidlo-Goldschmidt  posterior 
urethroscope.  This  instrument  showed  a  marked  conges- 
tion of  the  entire  posterior  urethra,  with  several  erosions. 
I  had  intended  to  make  direct  applications  to  the  posterior 
urethra  through  the  endoscope,  but  on  account  of  the 
extreme  congestion  present  (even  the  introduction  of  the 
instrument  or  of  a  sound  being  followed  by  hemorrhage)  I 
determined  first  to  relieve  the  congestion  by  instillations  of 
weak  silver  solutions  with  the  Bangs  sound  syringe,  gradu- 
ally increasing  the  strength  of  the  solution  and  the  size  of 
the  sound  syringe.  It  might  be  added,  in  passing,  that  in 
cases  where  applications  to  or  operations  in  the  posterior 
urethra  through  the  posterior  endoscope  are  necessary,  but 
where  there  is  such  extreme  congestion  of  the  parts  as  to 
preclude  the  passage  of  the  instrument,   I  have  found  it 


Unusual  Sexual  Neuroses.  287 

expedient  to  give  a  preliminary  treatment  as  above,  until 
the  congestion  was  relieved.  Accordingly,  every  fifth 
day  and  later  at  longer  intervals,  the  prostate  was  gently 
massaged  and  deep  instillations  of  very  weak  silver-nitrate 
solutions  given  (starting  with  i  :  3000  solution  and  a  16 
French  sound  syringe).  As  before  stated,  the  strength  of 
the  solution  and  the  size  of  the  sound  were  gradually 
increased,  with  the  result  that  the  attacks  at  first  became 
less  severe  and  later  ceased  altogether,  so  that  finally  it 
was  not  necessary  to  use  the  Goldschmidt  instrument  at  all 
in  order  to  make  direct  application. 

In  reviewing  this  case,  it  must  be  said  that,  while  reflex 
symptoms  coming  from  a  congested  prostate  and  posterior 
urethra  are  various  and  numerous,  I  have  never  seen  re- 
ported a  symptom-complex  like  the  above,  and  other  genito- 
urinary colleagues  with  whom  I  have  spoken  tell  me  that 
they  also  have  never  had  a  similar  case.  It  must  be  stated 
here,  that  had  the  picture  not  been  confused  by  the  findings 
in  the  anterior  urethra,  attention  would  certainly  have  been 
drawn  at  once  to  the  prostate  and  prostatic  urethra. 

Sexual  Neurasthenia  Due  to  Withdrawal. — M.  I>.,  re- 
ferred to  me  by  Dr.  Abrahamson  in  December,  19 12,  was 
39  years  old,  and  the  father  of  one  child.  He  came  to  the 
Neurological  Clinic  complaining  of  carelessness  in  work, 
loss  of  memory,  and  loss  of  all  sexual  desire  as  well  as 
general  nervousness.  He  admitted  having  practised  with- 
drawal for  some  time.  His  prostate  was  very  much  enlarged, 
while  the  deep  urethra  was  found  to  be  very  congested. 
Fortunately,  this  patient  was  separated  from  his  wife,  and. 
recovered  with  no  other  treatment  than  massage  of  the 


288  Disorders  of  the  Sexual  Function. 

prostate  and  a  few  direct  applications  of  lo^  silver  nitrate 
to  the  verumontanum. 

Examining  the  history  of  this  patient  in  retrospect,  we 
note,  as  has  been  repeatedly  pointed  out  heretofore,  that, 
like  very  many  similarly  afflicted,  he  did  not  seek  the 
genitourinary  specialist  complaining  of  sexual  symptoms, 
but  came  to  the  neurologist  complaining  of  the  most  vague 
neurasthenic  symptoms.  It  was  only  after  much  interro- 
gating that  the  etiological  factor  was  elicited. 

Pruritus  Ani  Due  to  Reflexes  from  the  Prostate. — Al- 
though cases  like  the  following  have  been  previously  re- 
ported, they  are  rare  and  not  generally  appreciated ;  so  that 
it  would  seem  advantageous  to  call  attention  to  the  condition. 

The  patient,  S.  T.,  complains  of  severe  itching  in  and 
also  about  the  anus.,  for  which  he  had  been  treated  without 
any  result  for  a  long  time.  He  is  30  years  old,  single,  and 
had  gonorrhea  six  years  ago.  Coitus  is  normal,  urination 
five  or  six  times  a  day  and  sometimes  at  night.  Seldom 
has  wet  dreams,  and  has  never  practised  masturbation. 
Urine  is  normal  except  for  the  presence  of  excess  of  ox- 
alates. Examination  shows  an  enlarged  prostate  and  fis- 
sures around  the  anus. 

Here  again  the  etiology  was  obscure.  Itching  is  a  very 
common  symptom  in  connection  with  anal  fissures,  and  one 
would  believe  the  etiology  to  be  very  simple.  However,  the 
patient,  before  coming  to  me,  had  been  carefully  treated 
for  a  long  time  for  this  condition,  without  result. 

I  treated  him  by  massaging  his  prostate  once  a  week, 
together  with  an  application  of  5  per  cent,  silver  nitrate  to 
his  anal  region.    The  result  was  that  after  only  four  treat- 


Unusual  Sexual  Neuroses.  289 

merits  his  pruritus  had  entirely  ceased  and  has  remained 
away  up  to  date.  For  theoretical  considerations  it  would 
perhaps  have  been  better  to  have  omitted  all  treatment 
except  the  prostatic  massage,  but  I  did  not  think  it  right 
to  omit  anything  that  might  prove  of  benefit  to  the  patient's 
most  distressing  condition,  even  though  the  etiological  fac- 
tors might  thereby  escape.  Perhaps  it  was  the  combination 
treatment  that  did  the  work,  but  certainly  the  massage  of 
his  prostate  must  have  contributed  greatly,  because,  as  above 
stated,  he  had  received  the  local  treatment  before,  without 
any  result. 

Sexual  Symptoms  in  a  Psychopath  Not  Dependent  upon 
Condition  of  the  Sexual  Organs. — I  desire  to  report  this 
case  as  a  direct  contrast  to  the  others,  showing  that  we 
may  have  cases  of  sexual  neurasthenia  with  pronounced 
sexual  symptoms,  with  definite  genitourinary  findings,  yet 
in  which  the  symptoms  are  entirely  psychic  and  only  re- 
motely caused  or  influenced  by  the  condition  of  the  genito- 
urinary apparatus.  Cases  like  the  present  one  ought  to  be 
reported  and  emphasized  in  order  to  prevent  us  from  claim- 
ing too  much,  and  so  make  the  genitourinary  specialist  too 
narrow,  causing  him  to  imagine  that  everything  revolves 
about  the  sexual  organs.  In  cases  like  the  following,  the 
genitourinary  specialist  should  call  the  neurologist  to  his 
aid,  and  the  latter  can  probably  cure  the  patient  by  psychic 
treatment : — 

H.  S.,  referred  by  Dr.  Ziegel  of  the  Mt.  Sinai  Dispen- 
sary, November  i,  1912.  He  is  single,  aged  21.  Six  years 
ago  he  practised  masturbation  almost  daily,  over  one  and 
a  half  years.    This  was  followed  by  a  continuous  prostator- 

19 


290  Disorders  of  the  Sexual  Function. 

rhea  lasting  five  weeks.  Two  years  ago  he  was  treated 
by  a  quack  physician  who  massaged  him  for  one  year.  His 
chief  complaint  is  that  he  imagines  he  feels  his  spermatic 
fluid  circulating  all  through  his  body.  He  believes  that  he 
will  not  get  well  until  his  system  is  rid  of  this  contamina- 
tion. He  expectorated  into  his  handkerchief  and  explains 
that  he  feels  and  sees  the  spermatic  fluid  in  the  saliva.  Now 
he  complains  of  pains  all  over  his  body  which  he  attributes 
to  the  action  of  the  spermatic  fluid  poisoning  his  entire  body. 

Examination  of  the  genitals  shows  a  varicocele  and  an 
atrophic  prostate.  The  posterior  urethra,  examined  by  the 
Wossidlo-Goldschmidt  posterior  urethroscope,  exhibits  a 
practically  normal  verumontanum,  with  a  marked  erosion 
in  the  left  lateral  sulcus,  and  with  an  erosion  at  the  open- 
ing of  the  left  ejaculatory  duct.  The  entire  urethra  is 
hypesthetic,  the  patient  experiencing  no  pain  or  ten- 
derness on  passage  of  the  instruments.  There  is  no  con- 
gestion of  the  verumontanum  and  the  entire  urethral 
picture,  as  well  as  the  condition  of  the  prostate  as  felt  per 
rectum,  is  the  direct  opposite  to  what  we  find  in  cases  of 
masturbation.  The  slightest  palpation  on  the  prostate  brings 
fluid  to  the  meatus.  He  urinates  every  two  hours  by  day 
and  rarely  by  night. 

With  this  pronounced  sexual  history  and  the  definite 
genitourinary  findings,  one  might  believe  the  relationship 
of  cause  and  eft'ect  very  direct.  However,  the  patient  came 
to  the  dispensary  at  irregular  intervals  and  was  treated  by 
deep  instillations  of  silver  nitrate,  and  direct  application 
of  strong  silver  solution  to  his  erosions  through  the  ure- 
throscope,   and    while   his    urethral    condition   cleared   up 


Unusual  Sexual  Neuroses.  291 

entirely,  and  while  there  were  no  pollutions  and  he  ceased 
to  masturbate,  yet  there  was  absolutely  no  improvement  in 
his  psychic  condition.  He  still  felt  his  spermatic  fluid 
coursing  through  his  entire  system.  I  believe  him  to  be  a 
psychopath  and  a  case  for  mental  rather  than  for  genito- 
urinary study. 

Severe  Anxiety  Neurosis  Due  to  Prostatic  Irritation.— 
This  case  is  reported  because  it  is  an  extreme  case  of  de- 
pression due  apparently  to  no  other  cause  than  reflexes 
originating  from  a  congested  prostate  induced  by  previous 
masturbation.  This  is  but  one  of  many  cases,  although  in 
general  they  do  not  present  such  severe  symptoms.  This 
case  did  not  come  into  the  genitourinary  clinic  for  exami- 
nation of  his  sexual  apparatus,  but  into  the  neurological 
department  of  Dr.  Abrahamson,  and  from  the  careful 
history  taken  in  this  department  the  relationship  was  easily 
recognized,  and  he  w^as  at  once  referred  to  me: — 

M.  G.,  single,  aged  26,  came  into  the  neurological 
department  of  Mt.  Sinai  Dispensary  on  November  3,  191 1. 
His  history,  as  copied  from  the  neurological  blank,  is  briefly 
as  follows :  Gonorrhea  four  times ;  last  attack  six  months 
ago.  Began  to  masturbate  at  14  and  stopped  three  years 
ago.  Duration  of  present  condition,  five  years.  Is  de- 
pressed; believes  that  his  face  does  not  look  as  it  should; 
believes  that  people  looking  at  him  realize  that  there  is 
something  wrong  with  him.  Knows  that  people  doubt  him. 
Memory  good;  sleeps  fairly  well;  dreams  rarely.  In  com- 
pany of  men,  feels  small ;  in  company  of  women,  feels  very 
small  and  bashful.  Believes  that  people  can  read  the  truth 
from  his  eyes  and  know  what  ails  him.     Hates  and  loves 


292  Disorders  of  the  Sexual  Function. 

all  women.  His  main  worry  is  his  eyes;  feels  sure  that 
if  his  eyes  were  different  he  would  feel  perfectly  well.  Feels 
that  his  eyes  are  weak  bcause  of  weak  nerves  brought  on 
by  Onanism  and  too  much  sexual  intercourse.  Life  is  not 
worth  living.  Does  not  masturbate  any  more.  Pollutions 
rarely.  Intercourse  every  two  or  three  weeks.  Sometimes 
believes  that  he  will  become  insane  and  believes  that  he 
knows  how  he  will  act  should  that  ever  happen.  He  is  very 
excitable  and  there  is  a  lack  of  concentration.  His  general 
appearance  is  dull  and  apathetic.  He  also  complains  of 
severe  headache  and  dizziness.  All  I  found  on  examination 
was  a  very  enlarged  and  tender  prostate.  The  only  treat- 
ment he  received  was  massage  of  the  prostate  once  a  week. 
At  the  end  of  two  months,  when  he  made  his  last  visit, 
practically  all  his  symptoms  had  left  him, 

I  suppose  that  many  neurologists  with  such  a  distinct 
sexual  history  would  consider  this  an  ideal  case  for  psycha- 
nalysis,  but  here  Dr.  Abrahamson  reversed  his  usual  pro- 
cedure and  had  the  sexual  apparatus  investigated  and 
treated  first,  before  resorting  to  psychic  treatment.  To  try 
to  cure  a  patient  by  psychic  treatment  alone,  while  there 
exists  a  constant  stream  of  reflex  irritation  sent  to  the 
brain  from  a  congested  prostate,  is  a  mistake  too  commonly 
made.  The  ardent  disciples  of  Freud,  in  their  enthusiasm, 
are  apt  to  be  entirely  too  narrow  in  their  interpretations. 

Tremor  of  Hands  Due  to  Prostatic  Irritation. —Tremor 
of  the  hands  is  a  common  symptom  in  many  nervous  affec- 
tions. In  fact  it  is  a  common  sign  of  "nervousness,"  using 
the  term  in  the  popular  sense,  but  it  is  rather  unusual  to 
find  it  the  only  symptom  of  a  congested  prostate. 


Unusual  Sexual  Neuroses.  293 

W.  S.,  single,  aged  20,  was  referred  to  me  in  June,  191 1. 
His  only  complaint  was  a  marked  tremor  of  the  hands 
which  interfered  with  his  business.  He  never  had  any- 
venereal  disease,  rarely  has  wet  dreams,  and  coitus,  though 
rare,  was  normal.  He  likes  to  "fool"  with  girls.  The 
only  thing  I  could  find  was  a  moderately  enlarged  but  rather 
tender  prostate  gland,  which  was  most  probably  the  result 
of  the  unnatural  sexual  excitement  of  too  much  spooning. 
He  received  no  medication,  and  was  treated  merely  by 
prostatic  massage  and  deep  urethral  instillations  of  silver- 
nitrate  solution.  He  was  also  cautioned  against  all  manner 
of  sexual  excitement.  As  a  result,  in  six  weeks  the  tremor 
had  entirely  disappeared.  He  remained  well  for  about  two 
years  and  then  returned  with  exactly  the  same  symptom 
again,  due  to  the  same  cause.  This  time  the  condition  was 
complicated  by  nocturnal  pollutions.  He  was  again  put 
on  the  same  treatment  with  the  same  good  result,  and  is 
at  present  absolutely  well.  How  foolish  it  would  have  been 
to  have  dosed  this  patient  with  bromides  or  to  have  given 
him  electricity  or  tonic  treatment! 

It  might  be  objected  by  some,  that  the  symptoms  as  well 
as  the  good  results  obtained  in  the  cases  just  outlined,  were 
not  due  to  the  conditions  found,  nor  to  the  treatment  of  the 
sexual  organs,  but  that  these  good  results  were  perhaps 
due  to  the  psychic  influence  of  the  treatment.  I  do  not 
wish  to  den}^  the  psychic  effect  produced  by  the  treatment. 
The  introduction  of  the  lighted  endoscope  or  cystoscope  is 
full  of  possibilities  hitherto  unknown  to  the  patient.  There 
is  first,  the  direct  seeing  of  the  disease  focus,  which,  like  an 
X-ray  examination,  appeals  especially  to  the  layman;  sec- 


294  Disorders  of  the  Sexual  Function. 

ondly,  the  patient  very  frequently  believes  that  light  and 
electricity  are  both  very  beneficial  in  their  therapeutic 
effects;  and  lastly,  the  novelty  of  the  procedure  impresses 
the  patient  with  the  thoroughness  of  the  examiner.  But  in 
spite  of  all  this,  which  in  some  cases  only,  is  a  concomitant 
feature,  I  feel  certain  that  the  good  results  were  mostly 
due  to  the  treatment  itself.  In  the  first  place,  the  lesions 
in  the  genital  apparatus  were  actually  present,  and  the 
symptoms  were  improved,  generally  parallel  with  the  im- 
provement in  the  local  condition.  But  what  is  significant 
is  the  fact  that  most  of  these  patients  had  received  treat- 
ment for  a  very  long  time,  with  other  procedures  which 
must  have  had  a  greater  hold  on  their  imagination  than  my 
treatment.  Take,  for  instance,  the  patient  with  attacks  of 
pain  in  his  penis.  At  first  the  dilatation  of  his  anterior 
urethra  with  the  Kollmann  dilator  has  absolutely  no  effect, 
either  good  or  bad,  on  his  symptoms.  If  the  case  were 
purely  psychic,  a  Kollmann  dilator  would  have  had  more 
effect  than  rectal  manipulation.  But  we  see  that  this  did 
not  occur,  and  he  only  got  well  as  soon  as  the  prostatic 
urethra  was  treated  and  the  local  lesion  cleared  up.  Going 
through  all  these  cases,  therefore,  we  note  that  almost  all 
of  them  were  treated  by  prostatic  massage  and  deep  ure- 
thral instillations, — procedures  which  are  certainly  not  at 
all  calculated  to  impress  the  imagination. 

I  wish  to  draw  attention  to  the  fact  that  the  various 
neuroses  are  psychanalytically  investigated  by  the  neuro- 
logical department  before  they  are  sent  to  me.  It  is  only 
after  failure  to  elicit  the  etiological  factor,  or  failure  of  the 
psychanalysis   itself  to  benefit  the  patient,   or   failure  of 


Unusual  Sexual  Neuroses.  295 

educational  attempts  of  therapeusis,  that  the  patient  is  re- 
ferred to  me  for  examination  and  possible  treatment. 

In  conclusion,  the  object  of  this  chapter  is  to  draw  atten- 
tion to  the  male  sexual  organs  as  the  cause  of  profound 
nervous  symptoms  in  many  cases.  I  do  not  wish  by  any 
means  to  convey  the  impression  that  the  male  sexual 
apparatus  is  the  hub  around  which  the  neuroses  revolve. 
I  have,  therefore,  purposely  reported  my  failure  to  cure  the 
patient  by  treatment  directed  to  his  sexual  organs,  in  one 
of  the  types  of  cases,  in  spite  of  the  fact  that  lesions  in 
these  organs  existed,  and  were  influenced  favorably  by 
treatment.  We  all  know  that  severe  nervous  symptoms 
may  follow  errors  in  refraction,  errors  in  digestion  and 
assimilation  and  other  reflex  irritations  from  almost  any 
organ  in  the  body,  but  I  do  plead  for  a  more  careful 
investigation  of  the  male  sexual  apparatus  in  functional 
nervous  diseases  in  such  cases  which  fail  to  respond  to 
treatment  and  where  the  etiology  remains  in  doubt. 


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Jour.,  Jan.,  1913;  abstr.  Urol,  and  Cut.  Rev.,  Dec,  1913. 

116.  Steinbacher,  J.:  Die  Mannliche  Impotenz  und  deren  radikale 
Heilung. 

117.  Still,  George  Frederic:  Common  Disorders  and  Diseases  of 
Childhood,  1912. 

118.  Stumpf,  J.:  Hygienic  Treatment  of  Nocturnal  Enuresis,  Bul- 
letin de  therapeutique,  Nov.  26,  1899;  abstr.  New  York  Med.  Jour., 
Dec.  16,  1899, 


Bibliography.  301 


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120.  Sturgis,  Frederick  R.  :    Sexual  Debility  in  Man,  1900. 

121.  Stirling,  William  :    Outlines  of  Practical  Physiology,  1895. 

122.  Swinburne,  George  Knowles  :  Disease  and  Treatment  of  the 
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123.  Talmey,  Bernard  S.  :    Neurasthenia  Sexualis,  1912. 

124.  Talmey,  Bernard  S.  :  Woman.  A  Treatise  on  the  Normal  and 
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125.  Tannenbaum,  Samuel  A. :  Sexual  Abstinence  and  Nervous- 
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126.  Taylor,  Robert  W.  :  A  Practical  Treatise  on  Sexual  Disorders 
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INDEX. 


Acquired   frigidity,   166 
Adenoids  and  enuresis,  211 
Alcohol,  as  a  cause  of  satyriasis, 

150  _ 
Alcoholic  priapism,   139 
Alcoholics,   in  masturbation,  8 

in  pollutions,  133 
Anesthesia  sexualis,   166 
Anus,    fissure    of,    as   a   cause    of 
enuresis,  211 
as  a  cause  of  vaginismus,  182 
Anxiety  neuroses,  291 
Atavistic  theory  of  satyriasis,  151 
Author's  experiments  in  enuresis, 
220 
investigations   in    frigidity,    171 
opinion  on  pathology  of  satyria- 
sis,  155 
on  relationship  of  lack  of  or- 
gasm to  sterility,  203 
Awkward    coitus,    as    a   cause    of 
vaginismus,    181 
as  a  cause  of  absence  of  or- 
gasm, 197 

Backache,   49 

Balanitis,  as  a  cause  of  enuresis, 

211 
Bangs'  sound  syringe,  32 
Baths,   in   pollutions,    133 
Belladonna,  in   enuresis,  217 
■Bibliography,  296 
Bicycle  riding  in  pollutions,   108 
Bladder,    contracted,    in    enuresis, 
209 
fissure   of  neck   of,   in   vaginis- 
mus, 182 
Bromides,  in  enuresis,  222 
in  functional  impotence,  89 
in  irritable  weakness,  82 
in  pollutions,  134 

Cantharides,   in   impotence,   96 
as  a  cause  of  priapism,  141 
Cardiac    sjnnptoms,    in    masturba- 
tion, 5,  48 


Cardiac  symptoms,  in  coitus  inter- 

ruptus,  234 
Carunculse  myrtiformes  in  vagin- 
ismus,  182 
Chordee,  140 

Circumcision   in   masturbation,   7 
Clitoris,     pathological      conditions 
of,  as  a  cause  of  absence 
of  orgasm,  200 
pathological  conditions  of,  as  a 
cause  of  frigidity,  169 
Clitoris   crises,   148 
Clitorism,  148 

Cocaine  in  vaginismus,   187 
Coitus,  awkward,   181,  197 
during  menses,  179 
excessive,  69 
illicit,   14 

interruptus      (see     also     With- 
drawal),   224 
as  a  cause  of  absence  of  or- 
gasm, 197 
as  a  cause  of  frigidity,  168 
as    a    cause    of    impotence    in 

the  male,  70 
as    a    cause    of    pollutions    in 

the  male,   108 
pathology   of,   in    female,   43 
mechanism  of,  in  end-organs,  63 
nervous    mechanism   of,   66 
physiology    of,    in    female,    43, 
198,  231 
in  male,  226 
proper  method  of,   178 
Complete  impotence,  55 
Congenital  frigidity,  166 
Continence,  252 
coitus,  illicit,   chances  of  infec- 
tion, 256 
impotence    and    continence,    76, 

84,  274 
masturbation  and  continence,  267 
satyriasis   and   continence,  269 
venereal    diseases,    abortion    of, 
259 
prevention  of,  256 

(303) 


304 


Index. 


Continence,  in  treatment  of  im- 
potence, 89 

Cystitis,  as  a  cause  of  enuresis, 
211 

Deep  urethral  instillation,  in  enu- 
resis, 220 
in  masturbation,  32 
Defecation    spermatorrhea,    107 
Demi-vierges,  185 
Diabetes,  in  enuresis,  211 

in  impotence,  76 
Diet,  in  enuresis,  217 

in  impotence,  89 

in  masturbation,  33 

in  pollutions,  133 
Dilatation,  in  vaginismus,  189 
Diurnal  pollutions,  107 
Dizziness,  23 

Dreams,  in  pollutions,  123 
Dribbling,  86 
Dyspareunia,  190 

definition,  190 

German    conception    of    term, 
190 

diagnosis,  191 

etiology,   190 

German    conception    of    dyspa- 
reunia, 190 

pathology,   190 

prognosis,   191 

symptoms,  191 

treatment,  191 
Dyspareunia,  in  the  male,  193 

definition,  193 

diagnosis,   195 

etiology,   194 

pathology,  194 

prognosis,  195 

symptoms,  194 

treatment,  195 

Ejaculation,    disturbance   of,   79 
premature,  72,  197 
rapid,  72,  82,  197 

Electricity,  in  enuresis,  222 

Enuresis,  208 
adenoids,  as  a  cause  of,  211 
anal  fissure,  as  a  cause  of,  211 
appealing  to  child's  pride,  216 
author's    experiments,    220 
balanitis,  as  a  cause  of,  211 
belladonna  treatment  of,  217 


Enuresis,  bladder,  contracted,  as  a 

cause  of,  209 
developing  of,  216 
brain  centers,  weak,  as  a  cause 

of,  209 
bromides,  222 

cystitis,  as  a  cause  of,  211 
deep  urethral  instillations  in,  220 
definition,  208 

enuresis  continua,  208 
enuresis  diurna,  208 
enuresis  nocturna,  208 
diabetes,  as  a  cause  of,  211 
diagnosis,  213 
diet,  217 
electricity,  222 
emptying    bladder    at    bed-time, 

216 
enuresis  continua,  208 
enuresis  diurna,,  208 
enuresis  nocturna,  208 
epilepsy,  as  a  cause  of,  211 
etiology,   208  _ 
fluids,  reduction  of,  217 
hyperthyroidism,  as  a  cause  of, 

211 
hypothyroidism,   as  a  cause   of, 

211 
idiopathic  enuresis,  210 
impotence  and  enuresis,  210 
Kerley's  treatment  of,  217 
lack  of  harmony  between  blad- 
der nerves,  as  a  cause  of, 

210 
lack     of     proportion      between 

bladder     muscles,     as     a 

cause  of,  210 
local    irritation,    treatment    of, 

216 
lumbar  centers,  hvperirritability 

of,  209 
puncture  in,  222 
lycopodium  in,  222 
meatus,  narrow,  as  a  cause  of, 

211 
nephritis,  as  a  cause  of,  211 
obstinate    cases,    treatment    of, 

219 
organic    nervous    disease,    as    a 

cause  of,  211 
pathology,  208 
adenoids,  211 
anal  fissure,  211 
balanitis,  211 


Index, 


305 


Enuresis,  pathology,  bladder,  con- 
tracted, 209 
brain    cells,    weak    and    unde- 
veloped, 209 
cystitis,  211 
diabetes,  211 
hyperthyroidism,  211 
hypothyroidism,   211 
idiopathic,  210 
impotence  and  enuresis,  210 
lack     of      harmony     between 

bladder  nerves,  210 
lack    of    proportion    between 

bladder  muscles,  210 
lumbar  centers,  hyperirntabil- 

ity  of,  209 
meatus,  narrow,  211 
nephritis,  211 

organic  nervous   disease,   211 
prepuce,  long  and  tight,  211 
rectal  polyp,  211 

worms,  211 
reflex  stimulation  of  bladder, 

209 
scrofula,  211 
vaginitis,  211 
pelvis,  elevated,  215 
prepuce,  long  or  tight,  211 
prognosis,  213 
prostatic  massage,  in  treatment 

of,  220 
pseudolumbar  puncture  in,  222 
psychic  element  in,  214 
punishment  in  treatment  of,  216 
rectal  polyp,  as  a  cause  of,  211 

worms,  as  a  cause  of,  211 
re-education,    in    treatment    of, 

221 
regulation  treatment,  217 
scrofula,  as  cause  of,  211 
sleeping    on    side,    in    treatment 

of,  215 
symptoms,  212 
taka-diastase  in,  222 
thyroid  extract  in,  221 
treatment,  214 

appealing  to  child's  pride,  216 
author's   experiments,    220 
belladonna,  217 
bladder,    contracted,    develop- 
ing of,  216 
bromides,  222 

deep  urethral  instillation,  220 
diet,  217 


Enuresis,  treatment,  electricity,  222 
emptying  bladder  at  night,  216 
fluids,   restriction  of,   217 
general,  215 
Kerley's  method,  217 
local  irritation,  treatment  of, 

216 
lumbar  puncture,  222 
lycopodium,  222 
obstinate   cases,   219 
pelvis  elevated,  215 
prostatic  massage,  220 
pseudolumbar   puncture,    222 
psychic  element,  214 
punishment,  216 
re-education,  221 
regulation  treatment,  217 
sleeping  on  side,  215 
taka-diastase,  222 
thyroid  extract,  221 
waking  child  at  night,  216 
'"wonderful  cures,"  214 
vaginitis,  as  cause  of,  211 
waking  child  at  night,  in  treat- 
ment of,  216 
"wonderful  cures,"  214 
Enuresis  continua,  208 
diurna,  208 
nocturna,  208 
Epilepsy,  as  a  cause  of  pollutions, 

108 
Erection,  disturbance  of,  79 
Eyes,  pain  in,  23,  86 

Fluids,   reduction  of,   in   enuresis, 

217 
Fossa  navicularis,  neuroma  of,  as 
a  cause  of  vaginismus,  182 
Fourchette,  fissure  of,  as  a  cause 

of  vaginismus,  182 
Frigidity,   166 

acquired  frigidity,  166 
definition,  166 
etiology,  167 
castration,    168 
coitus   interruptus,    168 
education,      faulty     method 

of,  168 
impotence,    167 
masturbation,    168 
penis,   undersized,   167 
psychic   conditions,    168 
vagina,  very  large,  167 
anesthesia  sexualis,  166 


20 


306 


Index. 


Frigidity,    author's    investigations 
in,  171 
castration,  as  a  cause  of,  168 
clitoris,  injuries  and  diseases  of, 

as  a  cause  of,  169 
coitus  during  menses,  in  treat- 
ment of,   179 
interruptus,  as  a  cause  of,  168 
proper    method    of,    in    treat- 
ment of,   178 
congenital   frigidity,   166 
definition,   166 
etiology,  169 
constrictor    cunni,    injuries    to, 

as  a  cause  of,  170 
definition,  166 

acquired  frigidity,   166 
anesthesia  sexualis,  166 
congenital    frigidity,   166 
orgasm,   lack  of,   166 
partial    frigidity,    166 
total  frigidity,  166 
diagnosis,   176 
education,    fautly    methods    of, 

as  a  cause  of,  168 
impotence,  as  a  cause  of,  167 
impotence    in    the    male,    as    a 

cause  of,  170 
intellectual     frigidity,     etiology, 

168 
inversion,  as  a  cause  of,  170 
masturbation,  168,  170 
menstruation,   scanty,   and   frig- 
idity, 171 
normal   frigidity,   167 
orgasm,  lack  of,  definition,  166 
partial  frigidity,  definition,   166 

pathology,  171 
pathology,  169 

author's   investigations,   171 
clitoris,   injuries  and  diseases 

of,  169 
constrictor  cunni,  injuries  to, 

170 
impotence  in  the  male,  170 
inverts,   170 
masturbation,   170 
menstruation,   scanty,    171 
partial   frigidity,   171 
sexual  passion,  lack  of,  171 
sterility,   171 
total   frigidity,   171 
vaginae  bulbi,  170 
penis,  undersized,  167 


Frigidity,  prognosis,  176 

psychic    conditions,    as    a   cause 

of,  168 
sexual     excitement,     simulation 

of,  in  treatment  of,  179 
sexual    instruction   to   husband, 

177 
sexual  passion  and  sterility,  171 
sexual  passion,  lack  of,  171 
sterility   and   frigidity,   171 
symptoms,  175 
total    frigidity,    definition,    166 

pathology,   171 
treatment,  177 

coitus  during  menses,   179 
coitus,  proper  method  of,  178 
sexual  excitement,   simulation 

of,  179 
sexual  instruction  to  husband, 
177 
uterus,    infantile,    and    frigidity, 

171 
vagina,   very   large,   as   a   cause 

of,  167 
vaginas  bulbi,  injuries  to,   170 
yohimbin,    179 
Frigidity,    not    lack    of    orgasm, 

196 
Functional  impotence,  61 

Gastrointestinal  symptoms,  due  to 
withdrawral,  241 

Genitals,  disproportion  between 
male  and  female,  200 

Genitourinary  symptoms  in  mas- 
turbation, 24 

Gonorrhea  and  impotence,  74 

Gonorrheal  priapism,  142 

Gymnastic  exercises  in  masturba- 
tion, 3 

Halbjungfrauen,  185 

Heart,  palpitation  of,  128 

Hirst's  operation,  189 

Horseback  riding,  as  a  cause  of 
pollutions,  108 

Hymen,  tough,  as  a  cause  of  va- 
ginismus,  182 
incision  treatment  of,  189 

Hyperesthesia  of  vaginal  mucous 
membrane,   182 

Hyperthyroidism  in  enuresis,  211 

Hypothyroidism  in  enuresis,  211 


Index. 


307 


Idiopathic  enuresis,  210 
Impotence  in  the  female,   103 
a  synonym  for  lack  of  orgasm, 

197 
definition,   103 
diagnosis,  104 
etiology,  103 
neurotic  impotence,  104 
non-obstructive  impotence,   104 
obstructive  impotence,  103 
pathology,  103 

neurotic  impotence,  104 
non-obstructive  impotence,  104 
obstructive  impotence,  103 
prognosis,  104 
symptoms,   104 
treatment,  105 
Impotence  in  the  male,  55 
bromides,    in    functional    impo- 
tence, 89 
in  irritable  weakness,  82 
cantharides,  96 
coitus,  excessive,  69 
interruptus,  70 

mechanism  of,  in  the  end-or- 
gans, 63 
nervous  mechanism  of,  66 
complete,  55 

continence    and    impotence,    76, 
84,  274 
in  treatment  of  impotence,  89 
definition,  55 

functional  impotence,  61 
organic  impotence,  56 
psychic  impotence,  99 
diabetes,  76 

diagnosis,    of    functional    impo- 
tence, 87 
limitation    of   posterior    en- 
doscopy in,  92 
of  organic  impotence,  60 
of  psychic  impotence,  102 
diet,  89 
dribbling,  86 

ejaculation,  disturbance  of,  79 
premature,  72 
rapid,  72,  82 
erection,  disturbance  of,  79 
etiology,     of     functional    impo- 
tence, 62 
of  organic  impotence,  56 
of  psychic  impotence,  99 
functional  impotence,  61 


Impotence,  functional,  bromides  in 
irritable  weakness,  82 
in  treatment  of,  89 
cantharides,    in    treatment   of, 

96 
coitus,    excessive,    as    a   cause 
of,  69 
interruptus,   as   a   cause   of, 

70 
mechanism    of,    in    end-or- 
gans, 63 
nervous  mechanism  of,  66 
continence,    in    the    pathology 
of,  76 
as  a  symptom  of,  84 
in  the  treatment  of,  89 
definition,  61 
diabetes,  76 
diagnosis,  87 
diet,  89 

ejaculation,  disturbance  of,  79 
premature,  72 
rapid,  72,  82 
erection,  disturbance  of,  79 
etiology,  62 
eyes,  pains  over,  as  a  symptom 

of,  86 
gonorrhea,  as  a  cause  of,  74 
headache,  86 

irritable  weakness  in,  81,  82 
legs,  pains  in,  86 
libido,  disturbance  of,  79 

seat  of,  68 
marriage    engagements,    long, 

as  a  cause  of,  76 
masturbation,    in    the    pathol- 
ogy of,  73 
psychic,  in  the  pathology  of, 
74 
nephritis,  77 
obesity,  77 
orgasm,  disturbance  of,  83 

seat  of,  83 
oxaluria  in,  78 
paralytic  impotence,  81,  82 
pathology,  62 

coitus,  excessive,  69 
interruptus,  70 
mechanism  of,  in  end-or- 
gans, 63 
nervotis  mechanism  of,  66 
continence,  76 
diabetes,  76 


308 


Index. 


Impotence,    functional,   pathology, 
ejaculation,  premature,  72 
rapid,  72 
gonorrhea,  74 
libido,  seat  of,  68 
marriage      engagements, 

long,  76 
masturbation,  7Z 

psychic,  74 
nephritis,  77 
obesity,  77 
,     oxaluria,  78 

sexual   excitement,   ungrati- 

fied,  75 
spooning,  76 

verumontanum,     action     of, 
65 
posterior     endoscopy,     impor- 
tance of,  92 
limitations  of,  92 
posterior    urethra,     treatment 

of,  90 
prognosis,  87 
prostatic  massage,  importance 

of  gentleness,  94 
psychic  masturbation,  74 
psychic  symptoms,  86 
sexual  excitement,  ungratified, 

as  a  cause  of,  75 
spooning,  76 
stimulants,  95 
strychnine,  82,  95 
suicide  and  impotence,  87 
symptoms,  79 
continence,  84 

ejaculation,    disturbance   of, 
79 
rapid,  82 
erection,  disturbance  of,  79 
eyes,  pains  over,  86 
general,  86 

eyes,  pains  over,  86 
headache,  86 
legs,  pains  in,  86 
psychic  symptoms,  86 
suicide,   87 
vertigo,  86 

weakness,  general,  86 
headache,  86 
irritable  weakness,  81,  82 
legs,  pains  in,  86 
libido,   disturbance  of,  79 
local,  79 
continence,  84 


Impotence,    functional,    sjanptoms, 
local,    ejaculation,    dis- 
turbance of,  79 
rapid,  82 
erection,    disturbance    of, 

79 
irritable  weakness,  81,  82 
libido,   disturbance  of,  79 
orgasm,     disturbance     of, 

83 
paralytic  impotence,  81,  82 
urination,  burning  on,  85 
frequency  of,  85 
pain  at  end  of,  86 
orgasm,  disturbance  of,  83 
paralytic  impotence,  81,  82 
psychic  symptoms,  86 
suicide,  87 

urination,  burning  on,  85 
freqviency  of,  85 
pain  at  end  of,  86 
vertigo,  86 

weakness,  general,  86 
treatment,  88 
bromides,  89 
cantharides,  96 
continence,  89 
diet,  89 

posterior  endoscopy,  impor- 
tance of,  92 
prostatic  urethra,  treatment 

of,  90 
prostatic  massage,  94 
stimulants,  95 
strychnine,  95 
verumontanum,       treatment 

of,  91 
yohimbin,  96 
urination,   burning  on,  85 
frequency  of,  85 
pain  at  end  of,  86 
vertigo,  86 

verumontanum,  action  of,  65 
weakness,  general,  86 
yohimbin,  96 
gonorrhea  and  impotence,  74 
headache,  86 
irritable  weakness,  81,  82 
libido,  disturbance  of,  79 
inhibited,  101 
misdirected,  100 
seat  of,  68 
marriage  engagements,  long,  as 
a  cause  of  impotence,  76 


Index. 


309 


Impotence,  masturbation,  73 
psychic,  74 
nephritis,  77 
obesity,  77 

organic  impotence,  56 
definition,  56 
diagnosis,  60 
etiology,  56 
pathology,  56 
prognosis,  60 
symptoms,  59 
treatment,  60 
orgasm,  disturbance  of,  83 

seat  of,  83 
oxaluria  in  impotence,  78 
paral3'tic  impotence,  81,  82 
partial  impotence,  55 
pathology    of    functional    impo- 
tence, 62 
of  organic  impotence,  56 
of  psychic  impotence,   100 
penes,  rudimentary,  57,  60 
pollutions  in  impotence,  86 
posterior  endoscopy,  imoortance 
of,  92 
limitations  of,  92 
posterior  urethra,  treatment  of, 

90 
prognosis    of    functional    impo- 
tence, 87 
of  organic  impotence,  60 
of  psychic  impotence,   102 
prostatic  massage,  94 
psychic  impotence,  99 
definition,  99 
diagnosis,   102 
etiology,  99 
libido,  inhibited,   101 

misdirected,   100 
pathology,  100 
prognosis,  102 
relative  impotence,  101 
roue,  impotence  of,  100 
sexual  perverts,  100 
symptoms,  100 
libido,  inhibited,  101 

misdirected,   100 
relative  impotence,   101 
roue,  impotence  of,  100 
sexual  perverts,  100 
treatment,  102 

psychic  masturbation  in  func- 
tional impotence,  74 


Impotence,    psychic    symptoms    in 
functional  impotence,  86 
relative  impotence,  101 
roue,  impotence  of,  100 
sexual    excitement,    ungratified, 
as  a  cause  of  impotence, 
75 
sexual  perverts,  100 
spooning,  76 

sterility  and  impotence,  55 
stimulants  in  impotence,  95 
strychnine  in  impotence,  82,  95 
suicide  and  impotence,  87 
symptoms    of    functional    impo- 
tence, 79 
of  organic  impotence,  59 
of  psychic  impotence,  100 
treatment    of    functional    impo- 
tence, 88 
of  organic  impotence,  60 
of  psychic  impotence,   102 
urination,  burning  on,  85 
frequency  of,  85 
pain  at  end  of,  86 
vertigo  in  impotence,  86 
A'erumontanum,  action  of,  65 

treatment  of,  91 
vesical  tenesmus,  86 
weakness,  general,  86 
yohimbin,  96 
Impotence  and  enuresis,  210 

and  pollutions,  128 
Impotence  in  the  male,  as  a  cause 
of  frigidity  in  the  female, 
170 
as  a  cause  of  lack  of  orgasm  in 

the  female,  197 
as    a    symptom    of    witlidrav/al, 
238 
Impotentia  masturbationis,  36 
pathology,  37 
symptoms,  36 
treatment,  37 
Infantile  masturbation,   11 
Incision    treatment    for    vaginitis, 

189 
Intellectual  frigidity,  168 
Inversion,  as  a  cause  of  frigidity, 
170 
as  a  cause  of  lack  of  orgasm  in 
the  female,  200 
Irritable  weakness,  81,  82 


310 


Index. 


Kerley's  treatment  of  enuresis,  217 
Klitorismus,  148 

Krafft-Ebing's  theory  of   satyria- 
sis, 154 

Law,  the,  and  vaginismus,  186 
Leukemic  priapism,  142 
Libido,  disturbance  of,  79 

inhibited,  101 

misdirected,  100 

seat  of,  68 
Lumbar    centers,    hyperirritability 
of,  as  a  cause   of  enure- 
sis, 209 

puncture  in  enuresis,  222 

Marriage,  as  a  cure  for  masturba- 
tion in  the  female,  53 
engagements,  long,  in  impotence, 
76 
in  female  masturbation,  39 
Married  females,  masturbation  in, 
39 
men,  masturbation  in,  25 
Masturbation,  1 
and  impotence,  73 
as  a  cause  of  frigidity,  168,  170 
as  a  cause  of  lack  of  orgasm  in 

the  female,  198,  199 
as  a  cause  of  pollutions,  108,  109 
as  a  cause  of  satyriasis,  151 
as  a  cause  of  vaginismus,  182 
before  adolescence,  2 
alcoholics,  8 
cardiac  disease,  5 
circumcision  in,  7 
coffee,  8 

course  and  prognosis,  6 
diagnosis,  5 
etiology,  3 
gymnastic  exercises,  3 
intertriginous  processes,  3 
nurses,  unscrupulous,  3,  8 
prepuce,  long  and  tight,  3 
spanking,  4 
urine,  acid,  3 
warm  feather  beds,  4 
worms,  3 
gynastic  exercises,  3 
intertriginous  processes,  3 
nurses,  unscrupulous,  3,  8 
onanism,  1 
pathology,  4 
in  precocious  cases,  4 


Masturbation   before    adolescence, 
prepuce  long  and  tight,  3 
prognosis,  6 
restraining  apparatus,  9 
side  pockets,  7 
spanking,  4,  8 
symptoms,  4 
cardiac,  5 
general,  4 
local,  4 

older  children,  5 
very  young  children,  4 
treatment,  7 
alcoholics,  8 
circumcision,  7 
coffee,  8 
general,  8 
prophylactic,   7 
restraining  apparatus,  9 
spanking,  8 
tea,  8 

watching,  9 
urine,  acid,  3 
watching  in  the  treatment  of, 

9 
warm  feather  beds,  as  a  cause 

of,  4 
worms,  3 
in  the  adult  female,  38 
backache,  49 
cardiac  symptoms,  48 
coitus  in  the   female,  physiol- 
ogy of,  43 
coitus    interruptus,    pathology 

of,  in  the  female,  43 
diagnosis,  50 
etiology.,  38 

in  married  females,  39 

in  unmarried  adult  females, 

38 
marriage  engagements,  long, 

39 
quack  advertisements,  39 
headache,  49 
labia  minora,  hypertrophy  of, 

45 
married    adult    females,    etiol- 
ogy of,  38 
marriage    engagements,    long, 

as  a  cause  of,  39 
marriage  as  a  cure  for,  53 
masturbation,   psychic,   in  the 
female,  41 
pathology  of,  42 


Index. 


311 


Masturbation  in  the  adult  female, 
methods  employed  in,  40 
pathology,  42 

of  coitus  interruptus,  43 
of  psychic  masturbation,  42 
physiology  of  coitus  in  the  fe- 
male, 43 
psychic  masturbation,  41 
quack  advertisements,  39 
symptoms,  44 
backache,  49 
cardiac,  48 
general,  46 
headache,  49 
labia    minora,    hypertrophy 

of,  45 
local,  44 

vulvitis,  masturbatory,  45 
treatment,  51 
general,  52 
local,  51 
marriage  in,  53 
unmarried  adult  females,  eti- 
ology, 38 
in  the  adult  male,  13 

Bangs'  sound  syringe,  32 

coitus,   illicit,   14 

conclusions,  34 

course  and  prognosis,  28 

deep  urethral  instillations,  32 

diet,  2>2> 

dizziness,  23 

eyes,  pains  in,  23 

genitourinary  symptoms,  24 

headache,  23 

married  men,  masturbation  in, 

25 
memory,  loss  of,  22 
pathology,  16 

of  psychic  masturbation,   19 
prognosis,  28 
prostate,  h3'peresthesia  of,  24 

massage  of,  31 
psychic   masturbation,    pathol- 
ogy,   19 
symptoms,  27 
as  a  cause  of  impotence,  74 
in  the  female,  41 
restraining  apparatus,  15 
symptoms,  20 
dizziness,  23 
eyes,  pains  in,  23 
genitourinary,  24 
headache,  23 


Masturbation    in   the    adult    male, 
symptoms,    memory,    loss 
of,  22 
prostate,  hyperesthesia  of,  24 
psychic  masturbation,  27 
thigh  muscles,  pains  in,  23 
urethra,  hyperesthesia  of,  24 
thigh  muscles,  pains  in,  23 
treatment,  29 

Bangs'   sound   syringe,  32 
deep  urethral  instillations,  32 
diet,  Z2, 

prostate,  massage  of,  31 
urethra,  hyperesthesia  of,  24 
masturbatio  impotentia,  36 
pathology,  Z7 
symptoms,  2i6 
treatment,  Z7 
masturbatio  incompleta,  Z6 
pathology,  Z7 
symptoms,  36 
treatment,  Z7 
masturbatio  interrupta,  35 
pathology,  Z7 
symptoms,  35 
treatment,  Z7 
pseudomasturbation    in    infants, 
10 
infantile  masturbation,    11 
thigh  friction,   11 
Meatus,    narrow,    as    a    cause    of 

enuresis,  211 
Memory,  loss  of,  in  masturbation, 
22 
in  pollutions,  128 
Menstruation,   scanty,   and   frigid- 
ity, 171 

Xephritis,  as  a  cause  of  enuresis, 
211 
as  a  cause  of  impotence,  77 

Nervous     exhaustibility     due     to 
withdrav/al,  237 

Neurasthenia,     general,      due     to 
withdrawal,  238 

Neurotic  impotence,  104 

Nocturnal  pollutions,  107 

Non-obstructive  impotence,   104 

Normal  frigidity,  167 
pollutions,  109 

Nurses,   unscrupulous,   in  mastur- 
bation, 3,  8 

Nymphomania,  159 
course,  164 


312 


Index. 


Nymphomania,  definition,  159 
diagnosis,   164 
etiology,  160 
pathology,  160 
prognosis,  164 

sterility  and  nymphomania,  164 
symptoms,  161 
treatment,  165 

Obesity  and  impotence,  77 
Obstructive  impotence,  103 
Onanism,  1   (see  Masturbation) 
as   a  isynonym   of   coitus   inter- 
ruptus,  225 
Organic  impotence,  56  (see  Impo- 
tence in  the  male) 
Orgasm,    absence    of,    in    the    fe- 
male, 19G 
author's    opinion,    on    rela- 
tionship    to     sterility, 
203 
clitoris,   pathological   condi- 
tions  as    a   cause    of, 
200 
coitus,  awkward,   197 
interruptus,  197 
physiology  of,  in   female, 
198 
diagnosis,  205 
definition,  196 

impotence   in   the   female, 

197 
lack  of  orgasm,   not   fri- 
gidity, 196 
not  dyspareunia,  197 
not  voluptuous   feeling, 
196 
dyspareunia,  not  lack  of  or- 
gasm,  197 
ejaculation,  premature,  197 

rapid,  197 
etiology,  197 
coitus,  awkward,  197 

interruptus,    197 
ejaculation,    premature, 
197 
rapid,  197 
impotence  in  the  male,  197 
masturbation,  198 
psychic  conditions,   197 
rape,  197 
frigidity,    not    lack    of    or- 
gasm, 196 


Orgasm,  absence  of,  in  the  female, 
genitals,  disproportion  be- 
tween sexes,  as  cause 
of,  200 
German  opinions  on  lack  of 
orgasm    and    sterility, 
203 
impotence  in  the  female,  197 
impotence  in  the  male,  as  a 

cause  of,  197 
inversion,  200 
masturbation,  198,  199 
pathology,    198 
clitoris,  200 
coitus,    physiology    of,    in 

female,  198 
genitals,  disproportion  of, 

200 
inversion,  200 
masturbation,  199 
perineal  fissures,  200 
rectovaginal  fistulse,  200 
vesicovaginal  fistulse,  200 
perineal  fissures,  200 
prognosis,  206 
psychic  conditions,  197 
rape,  197 

rectovaginal  fistulae,  200 
sterility    and    lack    of    or- 
gasm, 201,  203 
symptoms,  201 
sterility    and   lack   of   or- 
gasm, 201 
author's  opinion,  203 
German  opinions,  203 
treatment,  206 
vesicovaginal  fistulse,  200 
voluptuous  feeling,  not  lack 
of  orgasm,  196 
disturbance  of,  83 
lack  of,  definition,  166 
seat  of,  83 
Oxaluria  in  impotence,  78 

Paralytic  impotence,  81,  82 
Parke's  opinion  of  satyriasis,  154 
Partial  frigidity,  166 

impotence,  55 
Pelvis,    elevated,    in   treatment   of 

enuresis,  215 
Penis  captivus,  183 
pain  in  skin,  due  to  withdrawal, 
238 


Index. 


313 


Penis   undersized,   as  a   cause  of 
frigidity,  167 
rudimentary,  57,  60 
Perineal    fissures,    as    a    cause    of 

lack  of  orgasm,  200 
Physiology   of   coitus,   in   the    fe- 
male, 43,  198,  231 
of  coitus,  in  the  male,  226 
Pollutions,   in  the   female,   136 
Pollutions,  in  the  male,  106 
alcoholics,  133 
baths,  133 
bicycle  riding,  108 
bromides,  134 
coitus  interruptus,  108 
defecation     spermatorrhea, 
definition,  107 
pathology,  115 
symptoms,  126 
definition,  106 
of     defecation     spermator- 
rhea, 107 
of  diurnal  pollutions,   107 
of  nocturnal  pollutions,  107 
of  prostatorrhea,  107 
of  spermatorrhea,  106 
of  urethrorrhea,  108 
of  urination  spermatorrhea, 

107 
of  wet  dreams,  107 
diagnosis,  130 
diet,  133 

diurnal    pollutions,    definition, 
107 
pathology,  113 
symptoms,   125 
dreams  in  pollutions,  123 
epilepsy  and  pollutions,  108 
etiology,  108 
bicycle  riding,  108 
coitus  interruptus,  108 
epilepsy,  108 
horseback  riding,  108 
inflammation    of    the    pos- 
terior urethra,  108 
masturbation,  108,  109 
prostatic  massage,    108 
rectal  worms,  108 
sexual   excitement,   ungrati- 
fied,  108 
eyes,  burning  of,  as  a  symp- 
tom of,  128 
hands,  tremor  of,  128 
headache,  127 


Pollutions,  in  the  male,  heart,  pal- 
pitation of,  128 
horseback  riding,  108 
impotence  and  pollutions,   128 
inflammation  of  posterior  ure- 
thra,  as   a   cause   of, 
108 
lassitude  in  pollutions,  127 
masturbation,  108,  109 
memory,  loss  of,  128 
nocturnal     pollutions,     defini- 
tion,  107 
pathology,  112 
normal  pollutions,  109 
symptoms  of,  121 
pathological  pollutions,  symp- 
toms of,  122 
pathology,  110 

of     defecation     spermator- 
rhea, 115 
of  diurnal  pollutions,  113 
local,  114 

of  nocturnal  pollutions,  112 
of  urethrorrhea,  120 
perspiration,  excessive,  in  pol- 
lutions, 128 
posterior    urethra,    treatment 

of,  134 
prognosis,  131 
prostatic  massage,  as  a  cause 

of,  108 
prostatorrhea,  definition,   107 
psychrophore,  134 
rectal  worms,  108 
sexual     excitement,     ungrati- 

fied,  108 
spermatorrhea,  definition,   106 
defecation,   107 
pathology  of,  115 
symptoms  of,  126 
urination,  107 

symptoms  of,  126 
spine,  pains  in,  128 
spooning,  134 
symptoms,  121 
of      defecation     spermator- 
rhea, 126 
of  diurnal  pollutions,  125 
dreams,  123 
eyes,  burning  of,  128 
general,  127 

eyes,  burning  of,  128 
hands,  tremor  of,  128 
headache,  127 


314 


Index. 


Pollutions,  in  the  male,  symptoms, 
general,  heart,  palpitation 
of,  128 

impotence,  128 
lassitude,  127 
memory,  loss  of,  128 
perspiration,   excessive, 

128 
spine,  pains  in,  128 
testicles,  heaviness  of,  128 
urinary,  129 
hands,  tremor  of,  128 
headache,  127 
heart,  palpitation  of,  128 
impotence,  128 
lassitude,  127 
memory,  loss  of,  128 
of  normal  pollutions,  121 
of    pathological    pollutions, 

122 
perspiration,  excessive,    128 
spine,  pains  in,  128 
testicles,  heaviness  of,  128 
of  urethrorrhea,  130 
of  urination  spermatorrhea, 

126 
urinary,  129 
treatment,  133 
alcoholics,  133 
baths,  133 
bromides,  134 
diet,  133 
general,  133 
posterior  urethra,  treatment 

of,  134 
prophylactic,  133 
psychrophore,   134 
spooning,  134 

verumontanum,       cauteriza- 
tion of,  134 
urethrorrhea,  definition,  108 
pathology,  120 
symptoms,  130 
urinary    symptoms    of    pollu- 
tions, 129 
urination  spermatorrhea,  def- 
inition, 107 
symptoms,  126 
verumontanum,     cauterization 

of,  134 
wet  dreams,  107 
Pollutions  in  impotence,  86 
Posterior    endoscopy,    importance 
of,  in  impotence,  92 


Posterior     endoscopy,     limitations 
of,  92 
urethra,  treatment  of,  in  imipo- 
tence,  90 
in  pollutions,  134 
Prepuce,    long    and    tight,    as    a 
cause  of  enuresis,  211 

as  a  cause  of  masturbation,  3 
Priapism,  137 
in  adults,  137 
alcoholic,  139 

pathology,  139,  141 

symptoms,  143 

treatment,  147 
due  to  cantharides,  141 

pathology,  141 

symptoms,  142 
cerebral  cases,  prognosis  of,  147 
in  childen,  137 

etiology,  137 

symptoms,  142 
chordee,  pathology  of,  140 
definition,   137 
diagnosis,  146 
etiology,  137 

in  adults,  137 

in  children,  137 
gonorrheal,  142 

prognosis,  147 

symptoms,  142 

treatment,  147 
leukemic,  142 

pathology,  142 

prognosis,  147 

symptoms,  146 
pathology,  138 

alcoholic,  139,  141 

cantharides,  141 

chordee,  140 

leukemic,  142 

reflex,  139 

spinal,  138 

syphilitic,  139 

traumatic,  141 
prognosis,   146 

cerebral,  147 

gonorrheal,  147 

leukemic,  147 

reflex,  147 

sexual  perversion,  147 

spinal,  147 

tabes,  147 

traumatic,  147 
reflex,  139 


Index. 


315 


Priapism,  reflex,  pathology,  139 
prognosis,  147 
symptoms,  142 
treatment,  147 
sexual  perversion,  prognosis  in, 

147 
spinal  cases,  pathology  of,  138 
prognosis  in,  147 
symptoms  of,  143 
symptoms,  142 
alcoholic,  143 
cantharides,  142 
in  children,  142 
gonorrheal,  142 
leukemic,  146 
reflex,  142 
spinal,  143 
syphilitic,  pathology,  139 

treatment,  147 
tabes,  prognosis,  147 
traumatic,  141 
pathology,  141 
prognosis,  147 
treatment,  147 
treatment,  147 
alcoholic,  147 
gonorrheal,  147 
reflex,  147 
syphilitic,   147 
traumatic,  147 
Prostate,  congestion  of,  as  a  cause 
of  anxiety  neuroses,  291 
as  a  cause  of  pruitis  ani,  288 
as  a  cause  of  sexual  neuras- 
thenia, 284 
as  a  cause  of  tremor  of  hands, 
292 
hyperesthesia   of,    in    masturba- 
tion, 24 
massage  of,  in  enuresis,  220 
in  impotence,  94 
in  masturbation,  31 
as  a  cause  of  pollutions,  108 
Prostatorrhea,  107 
Pruritis  ani,  due  to  congestion  of 

prostate,  288 
Pseudolumbar  puncture  in  enure- 
sis, 222 
Pseudomasturbation  in  infants,  10 
infantile  masturbation,  11 
thigh  friction,  11 
Psychic  conditions,  as  a  cause  of 
frigidity,  168 


Psychic  conditions,  as  a  cause  of 
lack  of  orgasm  in  the  fe- 
male, 197 
element  in  treatment  of  enure- 
sis, 214 
impotence,  99 

masturbation  in  impotence,  74 
in  the  female,  41 
in  the  male,  19 
symptoms  in  impotence,  86 
Psychrophore  in  pollutions,  134 
Pulmonary    phthisis,    as    a    cause 

of  satyriasis,  150 
Punishment  in  enuresis,  216 

Quack  advertisements,  Z9 

Rape,  197 

Rectal  polyp,  as  a  cause  of  enure- 
sis, 211 
worms,  as  a  cause  of  enuresis, 
211 
as  a  cause  of  pollutions,  108 

Rectovaginal   fiustula,   as   a   cause 
of  lack  of  orgasm,  200 

Re-education,  in  the  treatment  of 
enuresis,  221 

Reflex  priapism,  139 

Relative  impotence,  101 

Restraining  apparatus  in  mastur- 
bation, 9,  15 

Roue,  impotence  of,  100 

Satyriasis,  150 
alcoholism,  as  a  cause  of,  150 
atavistic  theory  of,  151 
author's    opinion    of    pathology, 

155 
continence  and  satyriasis,   151 
diagnosis.   157 
definition,  150 
etiology,  150 

alcoholism,  150 

atavistic  theory,  151 

continence,  151 

masturbation,  151 

pulmonary  phthisis,   ISO 
Krafft-Ebing's  opinion,  154 
masturbation,  as  a  cause  of,  151 
Parke's  opinion,  154 
pathology,  154 

author's  opinion,  155 

Krafft-Ebing's  opinion,  154 


31G 


Index. 


Satyriasis,  pathology,  Parke's  opin- 
ion, 154 
Wulffen's  opinion,  154 
prognosis,  157 
pulmonary  phthisis,  150 
symptoms,  155 
treatment,  157 
Wulffen's  opinion,  154 
Sciatica,  due  to  withdrawal,  236 
Scrofula  and  enuresis,  211 
Sexual  excitem.ent,  simulation  of, 
in  frigidit}^  179 
ungratified,  as  a  cause  of  im- 
potence, 75 
as  a  cause  of  pollutions,  108 
instruction  in  frigidity,  177 
neurasthenia,  due  to  congestion 
of  prostate,  284 
Sexual     neuroses,     some    unusual 
forms  of,  282 
anxiety  neuroses,  291 
prostate,   congestion    of,   as   a 
cause  of  anxiety  neuroses, 
291 
as  a  cause  of  pruritus  ani, 

288 
as  a  cause  of  sexual  neuras- 
thenia, 284 
as    a    cause    of    tremor    of 
hands,  292 
pruritus  ani,  288 
sexual  neurasthenia,  284 
tremor  of  hands,  292 
withdrawal,  287 
passion  and  sterility,   171 

lack  of,  171 
perversion  and  impotence,  100 
and  priapism,  147 
Side  pockets  and  masturbation,  7 
Silver  nitrate  in  vaginismus,  188 
Spanking  in  masturbation,  4,  8 
Spermatorrhea,  106 
Spinal  cases  of  priapism,  138 
Spine,  pains  in,  128 
Spooning,    as    a    cause    of    impo- 
tence, 76 
as  a  cause  of  pollutions,  134 
Sterility  and  frigidity,   171 
and  impotence,  55 
and  lack  of  orgasm  in  the  fe- 
male, 201,  203 
and  nymphomania,  164 


Stimulants  in  impotence,  95 
Strychnine  in  impotence,  82,  95 
Suicide  and  impotence,  87 
Syphilitic  priapism,  139 

Tabes  and  priapism,  147 
Thigh  friction,  11 
Thigh  muscles,  pains  in,  23 
Total  frigidit}^  166 
Traumatic  priapism,  147 
Tremor  of  hands,  due  to  conges- 
tion of  prostate,  292 

Unmarried  adult  females,  mastur- 
bation in,  38 
Urethra,  hyperesthesia  of,  in  mas- 
turbation, 24 
Urethral  caruncle,   as  a  cause  of 
vaginismus,  182 
mucous  membrane,  prolapse  of, 
as  a  cause  of  vaginismus, 
182 
varicose  veins  of,  as  a  cause  of 
vaginismus,  182 
Urethrorrhea,   108 
Urinary    symptoms    of   pollutions, 

129 
Urination,  burning,  in  impotence, 
85 
frequency,  in  impotence,  85 
pain  at  end  of,  in  impotence,  86 
spermatorrhea,  107 
Urine,   acid,    as   a  cause   of  mas- 
turbation, 3 
Uterus,  infantile,  and  frigidity,  171 

Vagina,  very  large,  as  a  cause  of 

frigidity,  167 
Vaginae    bulbi,    injuries    to,    as    a 

cause  of  frigidity,  170 
Vaginal  dilators  in  vaginismus,  188 
Vaginismus,  180 

anus,  fissure  of,  182 

awkward  coitus,  181 

bladder  neck,  fissure  of,  182 

carunculje  myrti formes,  182 

cocaine,  187 

course,  185 

definition,   180 

demivierges,  185 


Index. 


317 


Vaginismus,  diagnosis,  185 
dilatation,  forcible,  189 
etiology,  180 
fossa    navicularis,    neuroma    of, 

182 
fourchette,  fissure  of,  182 
halbjungfrauen,   185 
Hirst's  operation,  189 
hymen,  tough,  182 
hyperesthesia  of  vaginal  mucous 

membrane,  182 
incision  treatment  of,  189 
law,  the,  and  vaginismus,  186 
masturbation,  182 
pathology,  181 

anus,  fissure  of,  182 
awkward  coitus,  181 
bladder  neck,  fissure  of,  182 
carunculse     myrtiformes,     in- 
flamed, 182 
fossa  navicularis,  neuroma  of, 

182 
fourchette,  fissure  of,  182 
hymen,  tough,  182 
hyperesthesia  of  vaginal  mu- 
cous membrane,   182 
masturbation,  182 
urethral  caruncle,  182 
urethral     mucous    membrane, 
prolapse  of,  182 
varicose  veins  of,  182 
penis,  captivus,  183 
prognosis,  185 
silver  nitrate,  188 
symptoms,  182 
demivierges,  185 
halbjungfrauen,  185 
penis  captivus,  183 
treatment,  186 
cocaine,  187 

dilatation,   forcible,   189 
general,  187 
Hirst's  operation,  189 
incision,  189 
prophylactic,  186 
silver  nitrate,  188 
vaginal  dilators,  188 
urethral  caruncle,  182 
urethral  mucous  membrane,  pro- 
lapse of,  182 
varicose  veins  of,  182 
vaginal  dilators,  188 


Vaginitis,  as  a  cause  of  enuresis, 

211 
Vertigo   in  impotence,   86 
Verumontanum,  action  of,  65 
appearance   of,   in   coitus   inter- 

ruptus,  229 
cauterization    of,    in    pollutions, 

134 
treatment,  of,  in  impotence,  91 
Vesical  tenesmus  in  impotence,  86 
Vesicovaginal  fistulas,   as  a  cause 

of  lack  of  orgasm,  200 
Voluptuous   feeling,   196 

Warm  feather  bed,  in  masturba- 
tion, 4 
Watching,    in    the    treatment    of 

masturbation,  9 
Weakness,  general,   in   impotence, 

86 
Wet  dreams,  107 
Withdrawal,  as  a  cause  of  sexual 

neurasthenia,  287 
Withdrawal,  the  evil  consequences 
of,  224    (see  also   Coitus 
interruptus) 
cardiac  symptoms,  234 
coitus,   physiology    of,    in    fe- 
male, 231 
in  male,  226 
course,  243 
diagnosis,  242 
definition,  225 
etiology,  225 

gastrointestinal  symptoms,  241 
impotence,  238 
nervous  exhaustibility,  237 
neurasthenia,  general,  238 
onanism,    as    a    synonym    of 

withdrawal,  225 
pathology,  226 

coitus,  physiology  of,  in  fe- 
male, 231 
in  male,  226 
verumontanum,    appearance 
of,  229 
penis,  pain  in  skin  of,  238 
prognosis,  243 
sciatica,  236 
symptoms,  232 
cardiac,  234 


318 


Index. 


Withdrawal,    symptoms,   gastroin- 
testinal, 241 
impotence,  238 
nervous  exhaustibility,  237 
neurasthenia,  general,  238 
penis,  pains  in  skin  of,  22,S 
reflex,  233 
sciatica,  236     ' 
sexual,  232 
treatment,  244 


Withdrawal,  verumontanum,  ap- 
pearance of,  229 

"Wonderful  cures"  in  enuresis 
214 

Worms,  as  a  cause  of  masturba- 
tion, 3 

Wulffen's  opinion  of  satyriasis,  154 

Yohimbin  in  frigidity,  179 
in  impotence,  96 


Studies  the  Psychology  of  Sex 

By   HAVELOCK    ELLIS,    L.S.A.     (England) 

Complete  in  Six  Crown  Octavo  Volumes 

Volumes  may  be  purchased  separately,  but  are  sold  only  by  subscription 
to  physicians,  lawyers,  clergymen,  advanced  teachers  and  scientists 

VOLUME  I 

Modesty,  Sexual  Periodicity,  Auto-Erotism 

Third  Revised  and  Enlarged  Edition. 
Ceown  Octavo,  355  Pages.  Extea  Cloth,  $2.50,  Net. 

THE  Evolution  of  Modesty.— The  Definition  of  Modesty.  Modesty  Based 
on  Fear.    Tlie  Sexual  Factor  of  Modesty.    In  Animals  and  in  Men,  etc. 

The  Phenomena  of  Sexual  Periodicity.— I.  The  Various  Physiological  and 
Psychological  Rhythms.  Menstruation,  etc.  II.  The  Question  of  a  Monthly 
Sexual  Cycle  in  Men.  Periodicity  in  Disease,  etc.  III.  The  Annual  Sexual 
Rhythm.    In  Animals.    In  Men.    The  Prevalence  of  Seasonal  Erotic  Festivals,  etc. 

Acto-erotism  :  A  Study  of  the  Spontaxeou.s  Manife.stations  op  the 
Sexual  Impulse. — I.  Definition  of  Auto-erotism.  The  Importance  of  this  Study, 
Especially  Today.  Auto-erotic  Phenomena  in  Animals,  Savages,  Barbaric  Races, 
etc.  II.  Hysteria  and  the  Question  of  its  Relation  to  the  Sexual  Emotions,  etc. 
III.  The  Prevalence  of  Masturbation.  Reasons  for  the  Sexual  Distribution  of 
Masturbation.  The  Immense  Part  in  Life  Played  by  Transmuted  Auto-erotic 
Phenomena,   etc. 

Appendix  A. — The  Influence  of  Menstruation  on  the  Position  of  Women. 

Appendix  B. — Sexual  Periodicity  in  Men. 

Appendix  C. — The  Auto-erotic  Factor  in  Religion.  Index.  Diagrams 
(Fourteen),  

VOLUME  II 

Sexual  Inversion 

Second  Revised  and  Enlarged  Edition. 
Ceown  Octavo,  391  Pages.  Extea  Cloth,  $2.50,  Net. 

I.    Introduction. — Homosexuality    Among    Animals.      Among    the    Lower 
Human  Races.     Among  Men  of  Exceptional  Intellect,  etc. 

II.    The  Study  of  Sexual  Inversion.— Westphal,  Hossli,  Casper,  Ulrichs, 
Tarnowsky,   Krafft-Ebing,   etc. 

III.  Sexual  Inversion  in  Men.— Relatively  Undifferentiated  State  of  the 
Sexual  Impulse  in  Early  Life.     Classification  of  the  Varieties,   etc. 

IV.  Sexual  Inversion  in  Women. — Prevalence  of  Sexual  Inversion  Among 
Women.    Physical  and  Psychic  Characteristics  of  Inverted  Women,  etc. 

V.  The  Nature  of  Sexual  Inversion.— Analysis  of  Histories.  Methods 
of  Sexual  Relationship,  etc. 

VI.  The  Theory  of  Sexu.\l  Inversion.— What  is  Sexual  Inversion?  Re- 
lation of  Inversion  to  Degeneration,  etc. 

VII.  Conclusions.— The  Prevention  of  Homosexuality.  Co-education.  The 
Treatment  of  Sexual  Inversion.    The  State  of  the  Law,  etc. 

Appendix  A. — Homosexuality  Among  Tramps. 

Appendix  B.— Ulrich's  View. 

Appendix  C— Letter  from  Professor  X. 

Appendix  D.— The  School-friendships  of  Girls. 

Appendix  E.— Countess  Sarolta  V. 

See  two  next  pages  jar  Vols.  Ill  to  VI. 

F.   A.    DAVIS   COMPANY,    Publishees, 
1914-16  Cherry  Street.  Philadelphia,  Pa. 


VOLUME   III 

Sexual  Impulse.    Love  and  Pain 

Second  Revised  and  Enlarged  Edition. 

Ceown  Octavo,  353  Pages.  Extea  Cloth,  $2.50  Net. 

Analysis  of  the  Sexual  Impulse. — Definition  of  Instinct,  etc. 

I.     Love  and  Pain. — The  Chief  Key  to  the  Relationship  Between 
Love  and  Pain  to  be  found  in  Animal  Courtship,  etc. 
II.     The  Fascination  of  Blood,  etc. 

III.  Causes  of  Connection  Between  Sexual  Emotion  and  Whip- 
ping, etc. 

IV.  The  Impulse  to  Strangle  the  Object  of  Sexual  Desire,  etc. 
V.     Pain  Felt  as  Pleasure,  etc. 

VI.     Why  is  Pain  a  Sexual  Stimulant?  etc. 
VII-     Summary  of  Results  Reached,  etc. 


THE  SEXUAL  IMPULSE   IN  V^OMEN 

I.     Introduction.     The  Primitive  View  of  Women,  etc. 
II.     Special  Characters  of  the  Sexual  Impulse  in  Women,  etc. 
III.     Summary  of  Conclusions. 
Appendix  A. — The  Sexual  Instinct  in  Savages. 
Appendix  B. — The  Development  of  the  Sexual  Instinct. 


VOLUME  IV 

Sexual  Selection  in  Man 

Crown  Octavo,  270  Pages.  Extra  Cloth,  $2.00,  Net. 

THE  FOUR  SENSES  INVOLVED 

PART  I.-TOUCH 

I.  The  Primitive  Character  of  the  Skin.  Touch  the  Earliest 
Sourse  of  Sensory  Pleasure.  The  Characteristics  of  Touch.  As  the  Alpha 
and  Omega  of  Affection. 

II.     Ticklishness.     Its  Origin  and  Significance.     The  Psychology  of 
Ticklishness.    The  Sexual  Relationship  of  Itching,  etc. 

III.  The  Secondary  Skin  Centers.  Orificial  Contacts.  The  Kiss. 
The  Significance  of  the  Association  Between  Suckling  and  Sexual  Emo- 
tion, etc. 

IV.  The  Bath.  Antagonism  of  Primitive  Christianity  to  the  Cult 
of  the  Skin.  Its  Cult  of  Personal  Filth.  The  Reasons  which  Justified 
this  Attitude,  etc. 

V.     Fundamental  Importance  of  Touch.     The  Skin  the  Mother  of 
AH  the  Other  Senses. 

PART  XL— SMELL.     PART  IIL-HEARING.     PART  IV. -VISION. 
I.     Primacy  of  Vision  in  Man.     Beauty  as  a  Sexual  Allurement. 
The  Objective  Element  in  Beauty.     Ideals  of  Feminine  Beauty  in  Vari- 
ous Parts  of  the  World.     The  Appeal  of  Beauty  Common  Even  to  Ani- 
mals and  Man. 

See  preceding  page  and  page  following  for  Vols.  I,  II,  V  and  VI. 

F.   A.    DAVIS   COMPANY,    Publishers, 
1914-16  Cherry  Street.  Philadelphia,  Pa. 


VOLUME  V 

Erotic    Symbolism 

Cbown  OctavOj  270  Pages.  Extea  Cloth,  $2.00,  Net. 

I.  Definition  of  Erotic  Symbolism. 

II.  Foot-fetichism  and   Shoe-feticliism,     The  Symbolism  of  Gar- 
ments. 

III.  Scatalogic  Sybmolism. 

IV.  Animals  as  Sources  of  Erotic  Symbolism. 

V.     Exhibitionism.     Illustrative  Cases,     A  Symbolic  Perversion  of 
Courtship.     The  Impulse  to  Defile. 

VI.     Forms  of  Erotic  Symbolism — Simulacra  of  Coitus. 

THE  MECHANISM  OF  DETUMESCENCE 

I.     The  Psychological  Significance  of  Detumescence.     The  Testis 
and  Ovary.     Sperm  Cell  and  Germ  Cell. 
II.     The  Object  of  Detumescence. 

III.  The  Constituents  of  Semen. 

IV,  The  Aptitude  for  Detumescence. 

THE   PSYCHIC  STATE   IN  PREGNANCY 

The  Relationship  of  Maternal  and  Sexual  Emotion.    Conception  and 
Loss  of  Virginitv. 

APPENDIX 

Histories  of  Sexual  Development. 

"The  volume,  as  a  whole,  may  be  said  to  be  a  careful,  painstaking,  and 
learned  exposition  of  the  problems  of  sex  of  which  it  treats,  and  can  be  con- 
fidently recommended  to  the  intelligent  seeker  after  light  in  this  most  obscure 
domain  of  psychology  as  being  quite  the  best  modern  work  in  English." — 
Journal  of  Mental  and  Nervous  Dise<i-ses. 


VOLUME  VI 

Sex  in  Relation  to  Society 

Cbown  Octavo,  656  Pages.  Extea  Cloth,  $3.00,  Net. 

-  I.  The  Mother  and  Her  Child.  II.  Sexual  Education.  III.  Sexual 
Education  and  Xakedness.  IV.  The  Valuation  of  Sexual  Love.  V.  The 
Function  of  Chastity.  VI.  The  Problem  of  Sexual  Abstinence.  VII. 
Prostitution.  VIII.  The  Conquest  of  the  Venereal  Diseases.  IX.  Sexual 
Morality.  X.  Marriage.  XI.  The  Art  of  Love.  XII.  The  Science  of 
Procreation. 

"I  have  great  respect  for  Dr.  Havelock  Ellis  and  the  work  he  has  done. 
I  have  examined  the  volume,  'Sex  in  Relation  to  Society,'  with  much  interest. 
I  say  without  hesitation  that  it  should  be  in  the  hands  of  probation  officers, 
judges,  and  specialists  of  every  kind  interested  in  the  subject  of  children.  It 
would  be  a  mighty  good  thing  if  every  sane,  sensible  parent  in  this  country 
could   also   interest   themselves   in   this   volume." — Bex   B.    Lindsay. 

See  two  preceding  pages  for  Vols.  I  to  IV. 

F.    A.    DAVIS    COMPANY,    Publishees, 
1914-16  Cherry  Street.  Philadelphia,  Pa. 


Indispensable  to  Physicians  and  Lawyers 

Medicolegal  Aspects  of 
Moral  Offenses 

BY 

L.    THOINOT,    M.D. 

Professor   in    the   Medical    Faculty   of    Paris;    Physician    to    Laennec    Hospital; 

Expert  to  the   Tribunal   of  the   Sedne;    Member  of   the  Academy   of 

Medicine  and  of  the  Society  of  Legal  Medicine  of  France. 

Translated  from  the  original  French  and  enla/rged  by 
ARTHUR  W.  WEYSSE,  A.M.,  Ph.D.  (Harvard),  M.D.  (BaseO 

Professor  in  Boston  University;  Member  of  the  Boston  Society 

of  Medical  Sciences,  The  Association  of  American 

Anatomists;  Fellow  of  the  A.  A.  A.  S.,  etc. 

Illustrated  with  17  Engravings,  Including  4  Charts  and  Diagrams. 

Only  Authorized  Translation  into  English. 

Royal  Octavo  Cloth,  $3.00,  Net. 


Sold  only  to  Doctors  and  Lawyers  and  Advanced  Students  of  the 
Medical  and  Legal  Professions. 


Condensed  Synopsis  of  Contents  •• — Outline  of  the  subjects  to  be 
treated:  Summary  Facts  of  Anatomy;  Rape  (5  chapters)  ;  Indecent  As- 
saults (3  chaijters)  ;  False  Assaults;  Public  Offenses  Against  Decency; 
Perversions  of  the  Sexual  Instinct;  Inversion  of  the  Sexual  Instinct; 
Inversion  of  Degenerates  or  Uranism;  Episodic  Inversion  of  the  Psy- 
choses; Inversion-vice;  Exhibitionism;  Fetichism;  Sadism  and  Maso- 
chism; Bestiality;  Necrophilia;  Nymphomania;  Satyriasis;  Erotomania. 

This  work  is  based  on  Dr.  Thoinot's  course  of  lectures  delivered  in 
the  Medical  School  of  Paris.  In  France  and  throughout  Europe  the 
author  is  known  and  acknowledged  as  the  leading  teacher  and  authority 
in  this  particular  field. 

While  there  are  a  number  of  excellent  treatises  on  legal 
medicine  in  our  language,  the  subject  of  sexual  offenses  has  received 
scant  attention.  The  author  may  be  said  to  have  employed  the  "case 
method"  of  teaching  now  used  in  our  leading  law  and  medical  schools. 


His  principles,  liis  deductions,  are  all  based  on  cited  cases;  many  of  his 
cases  are  new,  either  from  the  practice  of  his  colleagues  or  his  own. 

The  legal  aspects  of  the  subject  have  been  adapted  to  American  usage 
by  !Mr.  Everett  X.  Curtis,  S.B.,  LL.B.,  a  member  of  the  Massachusetts  bar 
and  a  prominent  practising  attorney  in  Boston.  There  is  an  Appendix 
on  the  laws  of  the  United  States,  containing  many  valuable  suggestions. 


Some  Reviews  and  Criticisms  of  Thoinot  and  Weysse  MedicolegaZ 
Aspects  of  Moral  Offenses. 

"I  have  received  your  'Medicolegal  Moral  Offenses,'  vrhich  I  have  read  with 
great  care  and  much  interest.  I  regard  it  as  a  very  valuable  addition  to  the 
Medicolegal  literature  upon  the  subjects  which  it  covers. 

"During  the  month  of  May,  I  prosecuted  one  ...  of  the  city  of  New 
Orleans,  for  the  crime  against  nature,  and,  although  he  was  convicted,  never- 
theless, at  the  time  of  the  trial  this  book  would  have  assisted  m-e  materially  in 
the  preparation  of  the  case. 

"It  is  a  practical  work,  and,  I  believe,  will  be  very  useful  to  lawyers  who 
practise  in  the  criminal  courts.  I  regard  the  chapters  upon  the  subject  of  rape 
as  particularly  useful  and  commend  them  to  the  District  Attorneys  throughout 
the  country." — St.   Claie  Adams,   District  Attorney   (New  Orleans,  La.) 

"Investigators  in  medicolegal  science  will  find  this  a  very  valuable  work. 
Though  designed  primarily  for  the  physician  who  is  interested  in  medicolegal 
studies,  the  book  will  furnish  much  of  value  to  the  lawyer,  and  especially 
to  the  criminologist,  for  it  is  not  a  study  in  pathology,  but  rather  of  legal 
medicine." — Yale  Law  Review. 

"For  its  scientific  analysis  of  perversions  of  the  sexual  instinct  the  book 
is  a  real  contribution  to  the  literature  of  legal  medicine." — American  Law  Review. 

"Crimes  against  morals  and  sexual  ofilenses  are  studied  from  a  scientific 
point  of  view  and  the  degenerate  brain  and  diseases  of  the  consciousness  of 
right  and  wrong,  and  the  incapability  to  act  and  live  normally,  are  the  sub- 
jects discussed.  The  author  concludes  that  the  great  army  of  submerge! 
morally  and  physically  are  diseased,  and  in  the  near  future  will  be  treated, 
studied,  and  prevented,  the  same  as  consumption,  typhoid  fever,  and  other 
epidemics.  To  lawyers  and  philanthropists  who  are  called  upon  to  study  and 
to  determine  means  of  prevention,  this  book  is  of  great  interest.  To  the 
casual  reader  the  psychological  side  of  crime  and  criminality,  along  these  lines, 
opens  up  a  new  and  very  startling  realm  that  gives  the  book  a  value  to 
students  of  causes  and  conditions  in  the  psychological  world." — Hartford 
{Conn.)  Post. 

"We  may  at  once  state  that  there  is  no  work  available  at  the  present  time 
for  the  medical  jurist  which  covers  exactly  the  same  ground  as  the  one  before 
us.  It  is,  in  fact,  like  Krafft-Ebing's  'Psychopa.thia  Sesualis,'  a  classic  in 
the  truest  sense.  In  France  and  Germany  a  great  advance  has  been,  made  both 
by  physicians  and  the  legal  profession  in  the  study  and  knowledge  of  offenses 
against  morality;  but  as  yet  we  are  extremely  backward  in  this  respect  in  this 
country.  .  .  .  It  is  unnecessary,  perhaps,  for  us  to  criticise  this  volume  in 
detail.  Suffice  it  to  say  that  no  matter  of  any  importance  bearing  on  the 
question  of  moral  offenses  has  been  omitted.  The  work  reflects  the  results  of 
painstaking  research  as  well  as  of  first-hand  knowledge.  It  is,  we  consider,  an 
indispensable  guide  not  only  for  the  general  practitioner  but  especially  for  the 
medical  jurist  and  the  coroner,  whose  ignorance  of  these  matters  is  often 
strikingly  shown  when  such  cases  are  tried  in  the  law  courts.  As  a  standard 
work  of  reference  we  can  give  Professor  Thoinot's  book  our  warmest  recom- 
mendation.    The  translation  is  an  excellent  one."— The  Medical  Times  (London). 

"The  moral  causes  of  rape,  the  existence  of  perverted  sexual  instincts,  are 
presumably  facts  which  are  from  time  to  time  objects  of  scrutiny  by  the  law; 
but  when  such  cases  occur  they  should  be  heard  in  camera,  and  only  placed  on 
record  for  reference.  The  book  we  are  reviewing  seems  to  be  exhaustive  of 
the  possibilities  of  such  extraordinary  behavior,  and  certainly  forms  an  ex- 
cellent work  of  reference  for  alienists  and  medicolegal  experts,  but  it  should 
otherwise  be  kept  under  lock  and  key."— Br/fi-sft  Medical  Journal. 

F.    A.    DAVIS    COMPANY,    Publishebs, 
1914-16  Cherry  Street.  Philadelphia,  Pa. 


The    One    Universally    Recognized  Authority 

Psychopathia  Sexualis 

WITH  ESPECIAL  REFERENCE  TO  CONTRARY 
SEXUAL  INSTINCT 

A  Medicolegal  Study  of    Sexual  Insanity 

BY 

Dr.  R.  von  KRAFFT-EBING 

Late   Professor  of   Psychiatry  and   Neurology,    University   of   Vienna. 
Authorized  Translation  from  the  German  by 

CHARLES  GILBERT  CHADDOCK,  M.D. 

Professor  of  Nervous  and  Mental   Diseases,   Marion-Sims    College  of 
Medicine,   St.   Louis,  etc. 

Royal  Octavo,  432  Pages.  Price,  Net,  Cloth,  $3.00. 

Sold  only  by  Subscription  to  Physicians  and  Lawyers  exclusively. 

General  Scheme  of  the  Book.— I.  Fragment  of  a  Psychology  of  the  Sexual 
Life;  The  Sexual  Instinct;  Sensuality  and  Morality;  True  Love,  etc.  II.  Physio- 
logical Facts;  Sexual  Maturity;  Control  of  the  Sexual  Instinct,  etc.  III.  General 
Pathology;  Importance  of  Pathological  Manifestations;  Sexual  Perversion.  IV. 
Special  Pathology;  Abnormal  Sexual  Manifestations  in  Mental  Diseases;  In- 
sanity. V.  Pathological  Sexuality  Before  the  Criminal  Court;  Frequency  of 
Sexual  Crimes;  Increase;  Loss  of  Responsibility,  etc. 

FROM  THE  PREFACE 

"The  purpose  of  this  treatise  is  a  description  of  the  pathological 
manifestations  of  the  sexual  life  and  an  attempt  to  refer  them  to  their 
underlying  conditions.  The  task  is  a  difficult  one.  .  .  .  But  the 
importance  of  the  subject  for  the  welfare  of  society,  especially  forensic- 
ally,  demands,  however,  that  it  should  be  examined  scientifically.  Only 
he  who,  as  a  medicolegal  expert,  has  been  in  a  position  Avhere  he  haa 
been  compelled  to  pass  judgment  upon  his  fellow-men,  where  life,  free- 
dom, and  honor  were  at  stake,  and  realized  painfully  the  incompleteness 
of  our  knowledge  concerning  the  pathology  of  the  sexual  life,  can  fully 
understand  the  significance  of  an  attempt  to  gain  definite  views  con- 
cerning it. 

"Even  at  the  present  time,  in  the  domain  of  sexual  criminality,  the 
most  erroneous  opinions  are  expressed  and  the  most  unjust  sentences  pro- 
nounced, influencing  laws  and  public  opinion. 

"The  following  pages  are  addressed  to  earnest  investigators  in  the 
domain  of  natural  science  and  jurisprudence. 

"It  is  hoped  that  this  attempt  to  present  to  physicians  and  jurists 
facts  from  an  important  sphere  of  life  will  receive  kindly  acceptance  and 
fill  an  actual  hiatus  in  literature." 

F.   A.    DAVIS    COMPANY,    Publishers, 
1914-16  Cherry  Street.  Philadelphia,  Pa. 


An     Unique    and    Important     Work 


Christianity  and  Sex  Problems 

BY 

HUGH   NORTHCOTE,  M.A. 

A  ISlew,  Thoroughly  Revised  and  Greatly  Enlarged  Edition. 
Crown  Octavo,  Nearly  500  Pages.  Price,  $3.00,  Net. 

In  this  new  carefully  revised  and  greatly  enlarged  edition  the  author 
has  worked  over  all  the  points  dealt  with  in  the  first  edition,  and  en- 
larged the  discussions  upon  them.  He  has  further  handled  a  fresh  series 
of  subjects,  has  explored  more  fully  the  philosophical  basis  of  sex 
morality;  and  has  introduced  a  considerable  additional  amount  of  his- 
torical material,  so  that  the  human  interest  of  the  subject  should  bring 
it  to  the  notice  of  all  readers  who  are  prepared  to  consider  sex  questions 
with  reverent  thoughtfulness. 

Delicacy  and  tactfulness  of  language  and  expression  have  been  main- 
tained so  far  as  consistent  with  fullness  and  clearness  of  teaching. 

TABLE  OF  CONTENTS— CONDENSED. 

INTRODUCTORY.  Ethic  of  the  Sexes — Science  of  Sex-literature  on.  Sex 
Questions — General  Result  of  Present  Inquiry — I.  General  View  of  Sex  Love— 
II.  Analysis  of  Sex  Love — III.  Sexuality  in  ChildtLood — IV.  The  Mixing  of  the 
Sexey  in  Schools  and  Institutions — V.  The  Battle  of  Chastity  in  the  Adult— 
VI.  Neomalthusianism — VII.  Sexual  Promiscuity — ^VIII.  Prostitution — IX.  Pros- 
titution and  the  Social  Sex  Process — X.  Prostitution  and  Rescue  Work — XI. 
Venereal  Disease  and  Legislation — XII.  Further  Applications  of  the  Principle 
of  Responsibility — XIII.  Marriage — XIV.  Spiritualized  Sexual  Love — XV.  Modesty 
—XVI.  Divorcf^XVII.  Forbidden  Degrees— XVIII.  The  Sexual  in  Art— XIX.  On 
the  Nature  and  Ethics  of  Impure  Language — XX.  Sexual  Perversions — XXI.  The 
Evolution  of  Sexual  Morality — XXII.  The  Metaphysical  Basis  of  Sexual  Morality 
—XXIII.    The  Virgin.  Martyrs— XXIV.   The  Gospel  and   Sex   Relations. 

APPENDIX  containing  additional  notes  on:  Primitive  Marriage;  Genesis 
Narrative  of  the  Fall;  The  Virgin  Birth  of  Our  Lord  Jesus  Christ;  Masturbation; 
Circumcision;  Nocturnal  Pollution;  Patristic  and  Medieval  Attitude  to  Divorce; 
Polygamy;  Belief  in  God;  The  Two  Fires;  Epilogue. 

Selections  from  the  Index  showing  wide  range  of  topics  treated: 

Adolescence.  Adultery,  Christian  interpretation  of;  in  the  Middle  Ages; 
punishment  of;  woman  taken  in.  Affinity.  Female,  conquest  of,  principle. 
Fertilty.  Flesh,  the.  Flirting.  Flogging  (see  Whipping).  Folly  of  girls.  For- 
nication; Biblical  views  of;  demoralization  effects  of.  Love,  conjugal;  moral 
considerations;  obligation  of;  of  God;  of  women;  passion;  sexual;  spiritualized; 
superior  to  asceticism.  Love-ecstasy,  a  moral  stimulus.  Marriage,  a  religious 
symbol;  accessible  to  soldiers;  age  for;  Christian  conception  of.  Marriage,  civil; 
contrasted  with  concubinage.  Sex,  a  factor  in  progress;  hunger;  knowledge; 
life,  ethical  ideals  of;  Christ  and  the;  love,  analysis  of;  metaphysical  basis  of. 
Sexual  ethics;  Christian;  evolution;  excess  in  marriage;  function,  imperfect  cen- 
tral of;  gratification,  how  far  necessary;  immaturity;  impurity;  instinct,  de- 
velopment of;   spiritualized;  instruction;  morality. 


F.    A.    DAVIS   COMPANY,    Publishebs, 
1914-16  Cherry  Street,    "  Philadelphia,  Pa. 


Plain  Talks  on  Avoided 
Subjects 

BY 

HENRY   N.    GUERNSEY,    M.D. 

Late  Professor  of  Obstetrics,  etc.,  in  the  Hahnemann 
Medical  College  of  Philadelphia. 

16mo.    Extra  Cloth.  Pkice,  50  Cents,  Net. 

Contents.— I.  Introductory.  II.  The  Infant.  III.  Childhood.  IV. 
Adolescence  of  the  Male.  V.  Adolescence  of  the  Female.  VI.  Marriage: 
The  Husband.  VII.  The  Wife.  VIII.  Husband  and  Wife.  IX.  To  the 
Unfortunate.     X.  The  Origin  of  the  Sex. 

A  compact  little  volume  which  squarely  and  truthfully,  and  yet 
most  tactfully  and  delicately,  treats  these  subjects  and  all  that  they 
involve.  It  will  prove  of  untold  value  to  every  young  man  and  young 
woman   in  the   land. 


The  Daughter 

HER    HEALTH,    EDUCATION   AND    WEDLOCK 
Homely  Suggestions  to  Mothers  and  Daughters 

By  WILLIAM  M.  CAPP,  M.D. 

I2mo.    Volume  of  150  Pages.  Extea  Cloth,  $1.00,  Net. 

This  is  just  such  a  book  as  a  family  physician  would  advise  his 
lady  patients  to  obtain  and  read.  It  answers  many  questions  which  every 
busy  practitioner  of  medicine  has  put  to  him  in  the  sick-room  at  a  time 
when  it  is  neither  expedient  nor  wise  to  impart  the  information  sought. 


"It  Is,  lOf  course,  a  book  for  mothers,  but  is  one  so  void  of  offense  in 
expression  or  ideas  tliat  it  can  safely  be  recommended  for  all  whose  minds  are 
sufficiently  developed  to  appreciate  its  teachings."— P7«?ade?pAia  Public  Ledger. 

"Many  delicate  subjects  are  treated  with  skill  and  in  a  manner  which 
cannot  strike  any  one  as  improper  or  bold.  The  absolute  ignorance  in  which 
most  young  girls  are  allowed  to  exist,  even  until  adult  life,  is  often  productive 
of  much  misery,  both  mental  and  physical.  Objectionable  features  will  not 
be  found  in  Dr.  Capp's  brochure,  and  for  this  reason  It  is  worthy  the  confidence 
of  physicians."— i/ecZtca?  News. 

"Just  such  a  book  as  we  have  long  desired  to  see.  Daintily  handled  and 
pure  in  sentiment  and  tone." — New  Englaml  Medical  Monthly. 

F.   A.    DAVIS    COMPANY,    Publishees, 
1914-16  Cherry  Street.  Philadelphia,  Pa. 


./ 


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